Crash of a Beechcraft B90 King Air in Dodge City: 3 killed

Date & Time: Feb 17, 2004 at 0257 LT
Type of aircraft:
Operator:
Registration:
N777KU
Flight Type:
Survivors:
No
Schedule:
Wichita - Dodge City
MSN:
LJ-377
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3066
Captain / Total hours on type:
666.00
Aircraft flight hours:
9005
Circumstances:
The emergency medical services (EMS) airplane was destroyed by terrain impact and post impact fire about 7 nautical miles (nm) west of its destination airport, Dodge City Regional Airport (DDC), Dodge City, Kansas. The 14 Code of Federal Regulations Part 91 positioning flight departed the Wichita Mid-Continental Airport (ICT), Wichita, Kansas, about 0215 central standard time and was en route to DDC. Night visual meteorological conditions prevailed when the accident occurred about 0257 central standard time. The flight had been on an instrument flight rules (IFR) flight plan, but the pilot cancelled the IFR flight plan about 34 nm east of DDC and initiated a descent under visual flight rules. Radar track data indicated that the airplane maintained a magnetic course of about 265 degrees during the flight from ICT to DDC. The rate of descent was about 850 to 950 feet per minute. During the descent, the airplane flew past the airport on a 270 degree course. Witnesses in the area reported hearing the engine noise of a low-flying airplane followed by the sound of impact. One of the witnesses described the engine noise as sounding like the engines were at "full throttle." The on-site inspection revealed that the airplane impacted the terrain in a gear-up, wings-level attitude. The inspection of the airplane revealed no anomalies to the airframe or engines. A review of the pilot's 72-hour history before the accident revealed that it had been 14 hours and 32 minutes from the time the pilot reported for duty about 1225 central standard time until the time of the accident. It had been 20 hours 57 minutes from the time the pilot awoke (0600) on the morning before the accident until the time of the accident. No evidence of pilot impairment due to carbon monoxide, drugs, or medical incapacitation was found. The accident occurred during a time of day that was well past the pilot's normal bedtime and also at a time of day when the physiological need to sleep is especially strong. The findings from a Safety Board's human performance analysis indicates that the pilot was likely fatigued. A review of 14 CFR 135.267 indicated that the pilot had adhered to the flight time limitations and rest requirements specified in the regulation.
Probable cause:
The pilot failed to maintain clearance with terrain due to pilot fatigue (lack of sleep).
Final Report:

Crash of a Fokker 50 in Sharjah: 43 killed

Date & Time: Feb 10, 2004 at 1138 LT
Type of aircraft:
Operator:
Registration:
EP-LCA
Survivors:
Yes
Schedule:
Kish Island - Sharjah
MSN:
20273
YOM:
1993
Flight number:
IRK1770
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
43
Captain / Total flying hours:
6440
Captain / Total hours on type:
1516.00
Copilot / Total flying hours:
3978
Copilot / Total hours on type:
517
Aircraft flight hours:
20466
Aircraft flight cycles:
19845
Circumstances:
The aircraft was operating as a scheduled flight from Kish Island, Iran to Sharjah, UAE with the captain initially as the pilot flying (PF). During the cruise and just prior to descent, the captain unexpectedly handed over control of the aircraft to the First Officer prior to the approach to Sharjah. The first officer did not accept this willingly and stated that he was not confident of his ability to conduct a VOR/DME approach into Sharjah. This statement was not consistent with his previous experience and could indicate either a cultural or professional issue. The captain insisted the first officer fly the aircraft and encouraged and instructed him during the approach. At 11:24 hours local time, the aircraft contacted Dubai Arrivals and was cleared from 9000 ft to 5000 ft and instructed to expect a VOR/DME approach to runway 12 at Sharjah International Airport. At 11:29 hours the aircraft was further cleared to 2500 ft and cleared for the approach. The aircraft was under its own navigation and the daylight conditions were fine with excellent visibility. At 11:35 hours the aircraft was instructed to contact Sharjah Tower and the pilot reported that the aircraft was established on the VOR final approach for runway 12. The Tower cleared IRK7170 to land and advised that the wind was calm. At that point the aircraft was slightly above the approach profile. The initial speed for the approach was at least 50 kt high at approximately 190 kt with no flap and no landing gear. The aircraft should have been configured with landing gear down and flap 10° during the approach and stabilized at 130 kt prior to the MDA. Approaching the MDA at flight idle setting, the autopilot was disengaged and the first Officer called for flap 10 at 186 kt (limiting speed of 180 kt) and flap 25 was selected by the Captain, a setting uncalled for by the Pilot Flying at 183 kt (limiting speed of 160 kt), and the landing gear was called for and selected at approximately 185 kt (limiting speed of 170 kt). The captain then took control of the aircraft and shortly afterwards the ground range selectors were heard by Cockpit Voice Recorder to be lifted and the power levers moved from the flight idle stop into the ground control range. The left propeller then went to full reverse whilst the right propeller remained in positive pitch within the ground control range. The aircraft descended in an extreme nose low left bank attitude until impact. The aircraft crashed 2.6 nm from the runway onto an unprepared sandy area adjacent to a road and residential buildings. The aircraft broke apart on impact and a fire started immediately. Three passengers suffered injuries while 43 other occupants were killed.
Probable cause:
During the final approach, the power levers were moved by a pilot from the flight idle position into the ground control range, which led to an irreversible loss of flight control. The following contributing factors were identified:
1. By suddenly insisting the First Officer fly the final approach, the pilot in command created an environment, which led to a breakdown of crew resource management processes, the non observance of the operator’s standard operating procedures and a resultant excessive high approach speed.
2. An attempt to rectify this excessive high approach speed most likely resulted in the non compliance with the Standard Operating Procedures and the movement of the power levers below flight idle.
3. The unmodified version of the Skid Control Unit failed to provide adequate protection at the time of the event.
Final Report:

Crash of an Ilyushin II-18D in Colombo

Date & Time: Feb 4, 2004 at 2233 LT
Type of aircraft:
Operator:
Registration:
EX-005
Flight Type:
Survivors:
Yes
Schedule:
Dubai – Colombo
MSN:
188 0111 05
YOM:
1968
Flight number:
EXV3002
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful cargo flight from Dubai, the crew started the descent to Colombo-Bandaranaike Airport by night and good weather conditions, using a GPS and DME systems. After being cleared to descend to FL150, the crew received the QNH and QFE values for Colombo: 1009 mb (hectopascals) and 756 mm Hg. The copilot mistakenly input 765 mm Hg instead of 756 mm Hg in the altimeters. At a distance of 14 km from the airport, the aircraft was 60 metres above the sea. It continued to descend until the undercarriage struck the water surface at a distance of 10,7 km from the runway 04 threshold. The captain decided to initiate a go-around procedure but shortly later, at a height of about 60-90 metres, he continued the approach. Assuming the undercarriage may have been damaged, he decided to carry out a belly landing. The aircraft landed 50 metres to the right of the main runway and 450 metres past its threshold. The aircraft then slid for a distance of 2,230 before coming to rest. All seven occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Beechcraft 1900D in Ghardaïa: 1 killed

Date & Time: Jan 28, 2004 at 2101 LT
Type of aircraft:
Operator:
Registration:
7T-VIN
Survivors:
Yes
Schedule:
Hassi R’Mel – Ghardaïa
MSN:
UE-365
YOM:
1999
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
1742
Circumstances:
The aircraft departed Hassi R'Mel-Tilrhempt Airport at 2030LT on a 15-minutes charter flight to Ghardaïa, carrying three crew members and two employees of the Sonatrach (Société Nationale pour le Transport et la Commercialisation d’Hydrocarbures). At 2044LT, the crew was cleared for a right hand circuit in preparation for an approach to runway 30. At that moment a Boeing 727 inbound from Djanet was on long finals. The copilot stated that he intended to carry out an NDB/ILS approach to runway 30. The captain however preferred a visual approach. The copilot carried out the captain's course and descent instructions with hesitation. At 2057LT, the EGPWS alarm sounded. Power was added and a climb was initiated from a lowest altitude of 240 feet above ground level. The captain then took over control and assumed the role of Pilot Flying. The airplane manoeuvred south of the airport until 2101LT when the copilot saw the runway. The captain rolled left to -57° and pitched down to -18.9° in order to steer the airplane towards the runway. Again the EGPWS sounded but the descent continued until the airplane impacted the ground and broke up. All five occupants were injured and the aircraft was destroyed. A day later, the copilot died from his injuries.
Probable cause:
The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

Crash of a Dassault Falcon 20C in Pueblo

Date & Time: Jan 21, 2004 at 0040 LT
Type of aircraft:
Operator:
Registration:
N200JE
Flight Type:
Survivors:
Yes
Schedule:
Saint Louis – Pueblo
MSN:
133
YOM:
1968
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3750
Captain / Total hours on type:
1900.00
Copilot / Total flying hours:
2850
Copilot / Total hours on type:
110
Aircraft flight hours:
8378
Circumstances:
The captain reported that he obtained weather briefings prior to and during the flight. The briefings did not include any NOTAMS indicating a contaminated runway at their destination airport. The captain obtained a report from the local fixed base operator that a Learjet had landed earlier and reported the runway as being okay. The tower was closed on their arrival, so they made a low pass over the airport to inspect the runways. Based on the runway and wind conditions, they decided their best choice for landing was on runway 08L. The captain said the landing was normal and the airplane initially decelerated with normal braking. As they encountered snow and ice patches, the captain said he elected to deploy the thrust reversers. The captain said that as the thrust reversers deployed, the airplane began to yaw to the left and differential braking failed to realign the airplane with the runway. The captain said the airplane departed the left side of the runway and rotated counter clockwise before coming to rest on a southwesterly heading. A witness on the airport said, "I watched them touch down. I heard the [thrust] reversers go on and then off, and then on again. As they came back on for the second time, that's when the plane started making full circles on the runway. This happened two, maybe three times before going off the side of the runway." The airplane's right main landing gear collapsed on departing the runway, causing substantial damage to the right wing, right main landing gear and aft pressure bulkhead. At the accident site, the right engine thrust reverser was partially deployed. The left engine thrust reverser was fully deployed with the blocker doors extended. An examination of the airplane revealed a stuck solenoid on the right engine thrust reverser. No other system anomalies were found. Approximately 33 minutes prior to the accident, the pilot requested from Denver Air Route Traffic Control Center, the weather for the airport. Denver Center reported the conditions as "winds calm, visibility 6 miles with light mist, 3,000 overcast, temperature zero degrees Centigrade (C) dew point -1 degree C, altimeter three zero 30.20, and there was at least a half inch of slush on all surfaces." The pilot acknowledged the information. The NOTAM log for the airport showed that at 2115, the airport issued a NOTAM stating there was "1/2 inch wet snow all surfaces." The airport operations manager reported that at the time of the accident the runway surface was covered with 3/4 inch of wet snow. The airport conducts a 24 hour, 7 days a week operation; however, operations support digresses to fire coverage only after 2300.
Probable cause:
The pilot's improper in-flight planning/decision to land on the contaminated runway, the stuck thrust reverser solenoid resulting in partial deployment of the right engine thrust reverser, and the pilot's inability to maintain directional control of the airplane due to the asymmetric thrust combined with a contaminated runway. Factors contributing to the accident were the wet, snow-covered runway, the airport's failure to remove the snow from the runway, and the pilot's failure to recognize the reported hazardous runway conditions by air traffic control.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Mulia

Date & Time: Jan 19, 2004
Operator:
Registration:
PK-WAX
Flight Type:
Survivors:
Yes
Schedule:
Wamena – Mulia
MSN:
255
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Mulia Airport, during the last segment, the aircraft was caught by downdrafts and lost height, causing the nose gear to land first. The aircraft went out of control, ground looped and came to rest in a ditch. The pilot, sole on board, escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Yakovlev Yak-40 in Tashkent: 37 killed

Date & Time: Jan 13, 2004 at 1927 LT
Type of aircraft:
Operator:
Registration:
UK-87985
Survivors:
No
Schedule:
Termez - Tashkent
MSN:
9 54 08 44
YOM:
1975
Flight number:
UZB1154
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
37
Aircraft flight hours:
37000
Circumstances:
Following an uneventful flight from Termez, the crew started the descent to Tashkent-Yuzhny Airport by night and marginal weather conditions. The visibility was limited due to foggy conditions with an RVR between 600 and 900 metres for runway 08L. The captain continued the approach with an excessive rate of descent, causing the aircraft to pass below the MDA without any visual contact with the ground. At an altitude of 165-170 metres, the captain positioned the airplane in a flat attitude then continued the descent at a distance of 2 km from the runway threshold, but this time with an insufficient rate of descent. The aircraft passed over the runway threshold at a height of about 30-40 metres and flew over the runway for a distance of 3,3 km. The captain established a visual contact with the runway lights, elected to land but failed to realize he was in fact approaching the end of the runway which is 4 km long. He reduced both engines power to idle, activated the thrust reversers when he realized his mistake and attempted a go-around. The aircraft collided with a 2 metres high concrete wall located 260 metres past the runway end, lost its right wing and crashed in a drainage ditch located along the perimeter fence, bursting into flames. The aircraft was totally destroyed and all 37 occupants were killed, among them Richard Conroy, special UNO representative in Uzbekistan.
Probable cause:
The following factors were identified:
- The crew failed to maintain a correct approach pattern maybe following a wrong setting of the approach selector in SP mode instead of ILS mode,
- The crew decided to continue the approach without establishing any visual contact with the approach light and runway light system,
- The crew failed to comply with published procedures,
- The crew failed to initiate a go-around procedure.

Crash of a Rockwell Grand Commander 690A in Cortez: 1 killed

Date & Time: Jan 3, 2004 at 1212 LT
Operator:
Registration:
N700SR
Flight Type:
Survivors:
No
Schedule:
Mesa – Cortez
MSN:
690-11164
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1872
Captain / Total hours on type:
91.00
Aircraft flight hours:
7506
Circumstances:
The pilot executed the VOR approach to runway 21. He was heard to report passing the VORTAC outbound for the procedure turn, and crossing the VORTAC (final approach fix) inbound. Witnesses said they saw the airplane emerge from the overcast slightly high and fast. They said the airplane entered a steep left bank and turned about 90 degrees before disappearing in a snow shower northeast of the airport. They heard no unusual engine noises. Another witness near the accident site saw the airplane in a steep bank and at low altitude, "just above the power lines." Based on the witness location, the airplane had turned about 270 degrees. The witness said the wings "wobbled" and the nose "dipped," then the left wing dropped and the airplane descended to the ground "almost vertically." Members of the County Sheriff's Posse, who were at a gunnery range just north of the airport, reported hearing an airplane pass over at low altitude. One posse member said he heard "an engine pitch change." He did not see the airplane because it was "snowing heavily," nor did he hear the impact. An examination of the airplane revealed no anomalies. At the time of the accident, the weather at the destination airport was few clouds 300 feet, 900 feet broken, 3,200 feet overcast; visibility, 1/2 statute and snow; temperature, 32 degrees F.; dew point, 32 degrees F.; wind, 290 degrees at 10 knots, gusting to 15 knots; altimeter, 29.71 inches.
Probable cause:
The pilot's inadequate planned approach and his failure to maintain airspeed which resulted in a stall. Contributing factors were low altitude flight maneuvering in an attempt to lose excessive altitude and realign the airplane for landing, and his failure to perform a missed approach, and the snow fall.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Koyukuk

Date & Time: Jan 2, 2004 at 1630 LT
Operator:
Registration:
N45008
Flight Type:
Survivors:
Yes
Schedule:
Galena – Koyukuk
MSN:
31-8052167
YOM:
1980
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5283
Captain / Total hours on type:
1400.00
Aircraft flight hours:
12808
Circumstances:
The Title 14, CFR Part 135 cargo flight departed for a destination airport about 20 miles downriver. Although weather at the departure airport was VFR, no reports of the actual weather along the route of flight were available. Unable to locate the destination airport due to deteriorating weather conditions, the pilot attempted to return to the departure airport following the river for ground reference. The airplane entered fog and whiteout weather conditions, and collided in-flight with the frozen surface of the river.
Probable cause:
The pilot's continued flight into adverse weather conditions, and his failure to maintain clearance from terrain, which resulted in an in-flight collision with terrain. Factors associated with the accident were fog and whiteout weather conditions.
Final Report:

Crash of a Piper PA-31T1 Cheyenne I in Dampierre-en-Yvelines: 3 killed

Date & Time: Jan 2, 2004 at 1625 LT
Type of aircraft:
Operator:
Registration:
N480CA
Flight Type:
Survivors:
No
Schedule:
Tel Aviv – Corfu – Toussus-le-Noble
MSN:
31-8004051
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
641
Circumstances:
The twin engine aircraft departed Tel Aviv on a flight to Toussus-le-Noble with an intermediate stop in Corfu, carrying two passengers and one pilot. On approach at 3,000 feet, the aircraft' speed and height dropped. It entered an uncontrolled descent and crashed in a wooded area located in Dampierre-en-Yvelines, about 10 km from the runway 07L threshold. All three occupants were killed.
Probable cause:
The loss of control is probably the consequence of a rapid icing of the airframe insufficiently or belatedly taken into account by the pilot. The following factors may have contributed to the accident:
- The pilot's fatigue generated by a flight period of 8 hours and 30 minutes in a single pilot configuration,
- The single pilot configuration imposes a high workload during a VOR-DME approach.
Final Report: