Crash of an Ilyushin II-76MD near Kerman: 275 killed

Date & Time: Feb 19, 2003 at 1724 LT
Type of aircraft:
Registration:
15-2280
Flight Type:
Survivors:
No
Site:
Schedule:
Zahedan - Kerman
MSN:
00634 71155
YOM:
1986
Country:
Region:
Crew on board:
18
Crew fatalities:
Pax on board:
257
Pax fatalities:
Other fatalities:
Total fatalities:
275
Circumstances:
The four engine aircraft departed Zahedan on a flight to Kerman, carrying 257 passengers and a crew of 18, most of them members of the Revolutionary Guards. On board were also several high ranking officers who just conducted a visit of the province of Zahedan, taking part to a narcotic control program. While descending to Kerman Airport by night, the crew encountered poor weather conditions with heavy snow falls and strong winds. On approach, the aircraft struck the slope of Mt Sirach located 32 km from the airport. First rescuers arrived on the scene the next morning. The wreckage was found about 100 metres below the summit and all 275 occupants have been killed.
Probable cause:
Controlled flight into terrain after the crew continued the descent below the MDA in poor visibility due to the night and bad weather conditions. For unknown reasons, the crew started the descent prematurely.

Crash of a Cessna 421A Golden Eagle I in Somerset: 3 killed

Date & Time: Feb 16, 2003 at 2002 LT
Type of aircraft:
Registration:
N421TJ
Survivors:
Yes
Schedule:
Griffith - Somerset
MSN:
421A-0051
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11732
Captain / Total hours on type:
518.00
Aircraft flight hours:
4129
Circumstances:
The airplane joined the inbound course for the GPS instrument approach between the intermediate approach fix and the final approach fix, and maintained an altitude about 200 feet below the sector minimum. The last radar return revealed the airplane to be about 3/4 nautical miles beyond the final approach fix, approximately 1,000 feet left of course centerline. An initial tree strike was found about 1 nautical mile before the missed approach point, about 700 feet left of course centerline, at an elevation about 480 feet below the minimum descent altitude. Witnesses reported seeing the airplane flying at a "very low altitude" just prior to its impact with hilly terrain, and also described the sound of the airplane's engines as "really loud" and "a constant roar." Night instrument meteorological conditions prevailed at the time of the accident. There was no evidence of mechanical malfunction.
Probable cause:
The pilot's failure to follow the instrument approach procedure, which resulted in an early descent into trees and terrain. Factors included the low ceiling and the night lighting conditions.
Final Report:

Crash of a Britten-Norman BN-2A-21 Defender at Braasschaat AFB

Date & Time: Feb 14, 2003
Type of aircraft:
Operator:
Registration:
B-03
Flight Type:
Survivors:
Yes
Schedule:
Braasschaat - Braasschaat
MSN:
476
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Braasschaat AFB. For unknown reasons, the twin engine aircraft landed hard and bounced several times before coming to rest on the runway. Both pilots escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of an Ilyushin II-76TD in Baucau: 6 killed

Date & Time: Jan 31, 2003 at 1521 LT
Type of aircraft:
Registration:
RDPL-34141
Flight Type:
Survivors:
No
Schedule:
Macau - Baucau
MSN:
00534 65941
YOM:
1985
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
14500
Copilot / Total flying hours:
6800
Aircraft flight hours:
2349
Aircraft flight cycles:
1400
Circumstances:
Carrying 31 tons of telecommunications equipments for a Portuguese telephone company, the aircraft departed Macau to Baucau with two passengers and four crew members. On approach, the aircraft impacted terrain near Caicido village during a landing approach, about 1 NM (1.87 km) to the northwest of Cakung Airport, Baucau, Timor-Leste. The pilot in command was the handling pilot during the descent and approaches at Baucau. The aircraft was destroyed by impact forces and a severe post-impact fire, and the six occupants were fatally injured. The occupants included the flight crew, which comprised the pilot in command, the copilot, the flight navigator and the flight engineer, and two loadmasters who did not form part of the flight crew. At the time of the occurrence, there was low cloud near the aerodrome.2 Witnesses at the aerodrome estimated the cloud base to be about 1,000 ft (305 m) above ground level, and visibility to be about 1,500 m (0.8 NM). Before the aircraft’s departure from Macau, the flight crew was provided with notices to airmen (NOTAMs) and weather forecast information for the planned flight. The weather information provided to the flight crew did not include a terminal aerodrome forecast (TAF), or an aviation routine weather report (METAR) for Baucau. Those weather forecasts were not produced for Baucau.
Probable cause:
The following findings were identified:
Air Traffic Services:
1. ATS was not available at Baucau at the time of the occurrence.
2. There was no procedure in place to provide flight crews of aircraft engaged in non-UN operations with an altimeter subscale setting for Baucau at the time of the occurrence.
Organisational factors:
1. Neither the Lao-based company, nor the Cambodian-based company, sought the consent for the proposed sublease, dated 18 November 2002, and accordingly the inferred sublease had not been finalised.
2. The Cambodian-based company was not the operator of the aircraft for the occurrence flight.
3. The Lao PDR was the State of Registry and State of the Operator.
4. The Lao DCA was responsible for the continued surveillance of the operator to ensure that the required standards of operation were maintained.
5. The operator provided flight crews with inflight CFIT avoidance procedures in its operations manual.
CFIT risk exposure:
1. The planned flight from Macau to Baucau was exposed to moderate risk of a CFIT event, based on historical CFIT data and the Transport Canada simple method of risk analysis.
2. The destination risk factors, type of operation, area of operation, weather conditions, and flight crew non-compliance with published procedures increased the CFIT risk exposure of the planned flight to an above-average level.
3. The consequences of the accident were catastrophic and resulted in loss of human life and damage to property and the environment.
4. Those catastrophic consequences resulted from the flight crew’s disregard of established procedures; that disregard bypassed all the safety criteria and inbuilt risk treatments in the design of those procedures and steadily increased the CFIT risk exposure to an extreme level during the latter stages of the flight.
Significant factors:
1. The flight crew did not comply the published non-precision instrument approach and/or missed approach procedures at Baucau during flight in instrument meteorological conditions.
2. The flight crew conducted user-defined non-precision instrument approaches to runway 14 at Baucau during flight in instrument meteorological conditions.
3. The pilot in command permitted the aircraft to descend below the MDA(H) published on both the Jeppesen and CAD runway 14 instrument approach charts during flight in instrument meteorological conditions.
4. The flight crew did not recognise the increased likelihood and therefore risk of CFIT.
5. The flight crew did not recognise or treat that risk in a timely manner.
Final Report:

Crash of a Boeing 737-2M9 in Rio Branco

Date & Time: Jan 26, 2003 at 1415 LT
Type of aircraft:
Operator:
Registration:
PP-SPJ
Survivors:
Yes
Schedule:
Belém – Manaus – Rio Branco
MSN:
21236
YOM:
1976
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7120
Captain / Total hours on type:
5271.00
Copilot / Total flying hours:
1348
Copilot / Total hours on type:
310
Aircraft flight hours:
54989
Circumstances:
Following an uneventful flight from Manaus, the crew started the descent to Rio Branco-Presidente Médici Airport runway 06 in marginal weather conditions with limited visibility due to fog. After passing the MDA at 1,150 feet, the crew continued the approach with an excessive rate of descent of 1,222 feet per minute. At a height of 57 feet, the aircraft struck trees located 360 metres short of runway 06 threshold. The engines lost power, the aircraft lost speed and height then struck the ground about 100 metres short of runway. Upon impact, the undercarriage were torn off and the aircraft slid on a distance of 600 metres before coming to rest. All 95 occupants escaped uninjured while the aircraft was destroyed.
Probable cause:
Poor approach configuration on part of the flying crew who continued the approach after passing the MDA at 1,150 feet while the aircraft was not stabilized and the crew did not establish a visual contact with the obstacles on short final. The following contributing factors were identified:
- Following the first impact with trees, branches and pieces of wood entered the engines, causing a loss of power followed by a loss of speed and altitude,
- Complacency on the part of the crew,
- Pressure and stress,
- Visual perception issues,
- Violation of the standard operating procedures,
- Loss of situational awareness,
- Lack of crew resources management,
- Poor approach and landing planning,
- Poor weather conditions,
- Relative low experience of the copilot.
Final Report:

Crash of a Cessna 208B Super Cargomaster in San Angelo

Date & Time: Jan 24, 2003 at 1015 LT
Type of aircraft:
Operator:
Registration:
N944FE
Flight Type:
Survivors:
Yes
Schedule:
San Angelo - San Angelo
MSN:
208B-0044
YOM:
1987
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4356
Copilot / Total flying hours:
13884
Aircraft flight hours:
7503
Circumstances:
The airplane impacted a dirt field and a power line following a loss of control during a simulated engine failure while on a Part 135 proficiency check flight. Both pilots were seriously injured and could not recall any details of the flight after the simulated engine failure. Witnesses observed the airplane flying on a westerly heading at an altitude of 100 to 200 feet, and descending. They heard the sound of an engine “surging” and observed the airplane’s wings bank left and right. The airplane continued to descend and impacted the ground and power lines before becoming inverted. A pilot-rated witness reported that he observed about ¼ inch of clear and rime ice on the airplane’s protected surfaces (deice boots) and about ½ inch of ice on the airplane’s unprotected surfaces. An NTSB performance study of the accident flight based on radar data indicated that the airplane entered a descent rate of 1,300 feet per minute (fpm) about 1,100 feet above the ground. This rate of descent was associated with a decrease in airspeed from 130 knots to 92 knots over a span of 30 seconds. The airplane’s rate of descent leveled off at the 1,300 fpm rate for 45 seconds before increasing to a 2,000 fpm descent rate. The true airspeed fluctuated between a low of 88 knots to 102 knots during the last 45 seconds of flight. According to the aircraft manufacturer, the clean, wing flaps up stall speed was 78 knots. However, after a light rime encounter, the Pilot’s Operating Handbook (POH) instructed pilots to maintain additional airspeed (10 to 20 KIAS) on approach “to compensate for the increased pre-stall buffet associated with ice on the unprotected areas and the increased weight.” With flaps up, a minimum approach speed of 105 KIAS was recommended. The POH also stated that a significantly higher airspeed should be maintained if ½ inch of clear ice had accumulated on the wings.
Probable cause:
The flight crew's failure to cycle the deice boots prior to conducting a simulated forced landing and their failure to maintain adequate airspeed during the maneuver, which resulted in an inadvertent stall and subsequent loss of control. A contributing factor was the ice accumulation on the leading edges of the airfoils.
Final Report:

Crash of a Cessna 402C in Sacramento

Date & Time: Jan 23, 2003 at 2030 LT
Type of aircraft:
Operator:
Registration:
N6814A
Survivors:
Yes
Schedule:
Ukiah – Sacramento
MSN:
402C-0645
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3400
Captain / Total hours on type:
350.00
Aircraft flight hours:
13817
Circumstances:
The airplane collided with obstructions following a loss of power in one engine during a missed approach. Following the collision sequence the airplane came to rest upright about 500 feet from the approach end of the runway and was destroyed in a post-impact ground fire. The pilot told a responding sheriff's deputy and a Federal Aviation Administration (FAA) inspector that he made the ILS approach to land and initiated a missed approach. When he added power, the left engine sputtered and the airplane veered to the left. He activated the fuel boost pump, but the airplane contacted obstructions and crashed. The responding sheriff's deputy also observed the accident. He heard an engine of an airplane making unusual sounds. The engine "seemed to get quiet and then revved higher as if to climb." He looked in the direction of the sound and saw a series of blue flashes and then an orange fireball. The deputy reported that there was a dense fog in the area at the time. At the time of the accident, the airport's weather conditions were reported as 100 feet overcast and 1/4-mile visibility in fog. The landing minimums for the ILS approach are 200 feet and 1/2-mile. According to the operator's records, when the airplane departed from Ukiah, its gross takeoff weight was about 5,909 pounds. The pilot operating handbook (POH) for the airplane lists the following items in the single engine go around checklist: 1) Throttle full forward; 2) wing flaps up; 3) when positive climb rate achieved, gear up; 4) ensure the inoperative engine is feathered. For a gross weight of 5,900 pounds, and the existing atmospheric conditions, the single engine climb performance chart shows an expected positive rate of climb of 500 feet per minute if the airplane was configured correctly. The chart also lists the following subtractions from that performance for the listed condition: 1) -400 fpm for wind milling inoperative engine; 2) -350 feet for landing gear down; 3) -200 fpm for flaps extended to 15 degrees. Examination of the wreckage disclosed that neither engine's propeller was feathered, the landing gear was down and the flaps were extended to 10 degrees. Without the airplane configured correctly for the single engine missed approach, the net climb performance would be a negative 400 feet per minute. There were no discrepancies noted with the airframe examination. The engine examination revealed no mechanical anomalies with either engine that would have precluded normal operation. 14 CFR 135.224 states that a pilot cannot initiate an approach if the weather conditions are below landing minimums if the approach is started outside of the final approach fix. The pilot can continue the landing if they are already established on the approach and the airport goes below landing minimums. According to the operator's FAA approved operating specifications, the operator had not been approved for lower than standard landing minimums.
Probable cause:
Loss of engine power in the left engine for undetermined reasons. Also causal was the pilot's failure to correctly configure the airplane for a single engine missed approach, which resulted in a negative climb performance. A factor was the pilot's decision to initiate the approach when the weather conditions were below the published approach minimums.
Final Report:

Crash of a Fokker 50 in Mellila

Date & Time: Jan 17, 2003 at 1201 LT
Type of aircraft:
Operator:
Registration:
PH-FZE
Survivors:
Yes
Schedule:
Málaga – Melilla
MSN:
20182
YOM:
1990
Flight number:
YW8276
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12900
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
457
Copilot / Total hours on type:
64
Aircraft flight hours:
22534
Aircraft flight cycles:
25803
Circumstances:
After landing on runway 15 at Melilla Airport, the pilot-in-command noticed that he could not engage the ground idle/reverse of both propellers, and that the aircraft did not brake normally. The aircraft started to deviate to the left of the runway axis while both pilots were applying brakes. After tyre n°3 burst, the deviation continued until the aircraft left the paved surface of the runway and finally fell through an embankment with around 15 metres of height located at the end of runway 15. The aircraft was destroyed and the pilot-in-command and other nine people suffered minor injuries. There was no fire.
Probable cause:
It is considered that the accident probably happened because of a combination of three factors:
1. An unstable approach that resulted in a higher than normal touchdown speed.
2. The inability to select propeller reverse due to the probable tripping of the circuit breaker FLIGHT IDLE SOLENOID 1 & 2 before or at touchdown.
3. The cross connection of the wheel speed transducer wire harness of wheels 3 and 4, which, due to heavy braking, produced a flat spot in wheel 3 and reduced the braking capability of wheel 4.
Final Report:

Crash of a BAe 3101 Jetstream 31 in Yacuiba

Date & Time: Jan 17, 2003 at 0900 LT
Type of aircraft:
Operator:
Registration:
CP-2404
Survivors:
Yes
Schedule:
Yacuiba - Santa Cruz
MSN:
680
YOM:
1985
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8194
Copilot / Total flying hours:
832
Circumstances:
During the takeoff roll at Yacuiba Airport, at V2 speed, the right engine lost power. The captain decided to continue the takeoff procedure. During initial climb, decision was taken to return for an emergency landing and the crew shut down the right engine and feathered its propeller. After touchdown on runway 20, the aircraft was unable to stop within the remaining distance, overran, lost its nose gear and collided with bushes and small trees, coming to rest about 50 metres past the runway end. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Excessive speed upon landing,
- Delayed application of the brake systems,
- The runway length available was limited according to the conditions in force,
- The total weight of the aircraft upon landing,
- The aircraft configuration,
- The direction and intensity of the wind,
- An inadequate crew training.
Additionally, the exact cause of the loss of power on the right engine was not clearly determined at the time the final report was published.
Final Report:

Crash of an Antonov AN-26B in Ndjolé: 7 killed

Date & Time: Jan 17, 2003
Type of aircraft:
Operator:
Registration:
ER-AFT
Flight Type:
Survivors:
No
Schedule:
Brazzaville - Douala
MSN:
134 03
YOM:
1984
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft departed Brazzaville on a delivery flight to Douala. While cruising by night over Gabon, the crew informed ATC about technical problems, declared an emergency and elected to divert to the nearest airport which was Ndjolé. This airfield was not equipped with any runway or approach lights nor any navigation aids. The crew completed several circuits over the city then people parked their cars along the airstrip so the crew was able to land. After four unsuccessful attempts, the crew tried to land but the aircraft flew over the runway without landing, passed over the Ogooué River and eventually crashed in a wooded and swampy area. The crew of two helicopters from the Gabonese Air Force found the wreckage the following day. The aircraft was destroyed and all seven occupants were killed. Until few days prior to the accident, the aircraft was operated by Pont Aviation which bankrupted, so it was transferred to another operator in Cameroon.
Probable cause:
It is believe that the crew was forced to make an emergency landing following a general failure of the navigation instruments in flight.