Crash of a Fokker F27 Friendship 600 in Saint Peter: 2 killed

Date & Time: Jan 12, 1999 at 1706 LT
Type of aircraft:
Operator:
Registration:
G-CHNL
Flight Type:
Survivors:
No
Schedule:
Luton - Saint Peter
MSN:
10508
YOM:
1975
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3930
Captain / Total hours on type:
750.00
Copilot / Total flying hours:
958
Copilot / Total hours on type:
317
Circumstances:
The Fokker F27 was operating on a cargo flight to Guernsey, carrying newspapers. The aircraft departed Luton at 16:14. and climbed to cruising altitude FL150/160). The descent was begun at about 60 miles from Guernsey Airport and the aircraft was vectored onto final approach by Jersey Radar. The approach checklist was actioned and the flaps were lowered to 16° just before the aircraft was turned to intercept the ILS localizer. With less than six miles to run to the threshold the commander told the first officer that he could see the runway and was content to continue the approach visually. The first officer informed ATC that they wished to continue the approach visually; they were given the appropriate clearance and control of the aircraft was then handed over to Guernsey Tower. Initially the aerodrome controller cleared the aircraft to continue the approach (there was departing traffic on the runway) and the commander called for flaps to 26° followed by the landing checklist. About one minute later the commander said "three whites" (meaning that he was aware that the aircraft was slightly high on the glide path indicated by the precision approach path indicator lights) which the first officer acknowledged. The commander then said "ok the decision is to land, speed below one four four, flaps forty". The first officer acknowledged the instruction to select flaps to 40° and announced "running". There followed a pause of about five seconds before the first officer said, "flaps forty gear and clearance you have - oops". The commander then said, in an anxious tone of voice "ok flaps twenty six" and the engines could be heard accelerating on the cockpit voice recording. There then followed a number of expletives from the commander interspersed with some loud clicks as controls or switches were operated and the sound of a warning horn which stopped before the end of the recording. On approach the aircraft had lost control, attaining a nose-high attitude. The plane stalled, clipped a house on Forest Road with its left wing and ploughed into a field short of the runway.
Probable cause:
The investigation identified the following causal factors:
(i) The aircraft was operated outside the load and balance limitations;
(ii) Loading distribution errors went undetected because the load sheet signatories did not reconcile the cargo distribution in the aircraft with the load and balance sheet;
(iii) The crew received insufficient formal training in load management.
Final Report:

Crash of a Hindustan Aeronautics HAL-748-219-2 at Arakkoram-Rajali NAS: 8 killed

Date & Time: Jan 11, 1999 at 1545 LT
Operator:
Registration:
H2175
Flight Type:
Survivors:
No
Schedule:
Arakkoram – Tambaram
MSN:
569
YOM:
1978
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
After takeoff from Arakkonam-Rajali NAS, en route to Tambaram AFB, the pilot contacted ATC and declared an emergency and reported major technical problems. He was cleared to return for an emergency landing. On final approach, the aircraft went out of control and crashed in a wooded area located 2,5 km short of runway. The aircraft was destroyed and all eight occupants were killed.
Probable cause:
It is believed that the crew lost control of the aircraft following the separation of the dome located on the top of the fuselage that was recovered about 500 metres from the main wreckage.

Crash of a Mitsubishi MU-2B-60 Marquise in Egelsbach

Date & Time: Jan 11, 1999
Type of aircraft:
Operator:
Registration:
N95MJ
Flight Type:
Survivors:
Yes
Schedule:
Egelsbach - Egelsbach
MSN:
1564
YOM:
1983
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On January 11 1999, during a local check flight for the new owner-pilot, as the aircraft was descending through about 150 feet during the final stage of a visual approach to Runway 27 at Frankfurt Egelsbach Airport, Egelsbach, the pilot 'pulled the throttles back to ground idle.' The check pilot immediately moved the throttles forward again but meanwhile the aircraft had developed a high rate of descent and it touched down very hard on the threshold of Runway 27 wherein the nose gear and left main landing gear broke off.

Crash of a Casa 212 Aviocar 200 in Kinshasa: 5 killed

Date & Time: Jan 11, 1999
Type of aircraft:
Operator:
Registration:
802
Flight Type:
Survivors:
No
Schedule:
Harare - Kinshasa
MSN:
295
YOM:
1983
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Crashed in unknown circumstances while approaching Kinshasa, killing all five crew members who were completing a flight on behalf of the Government of Zimbabwe.

Crash of a Beechcraft 1900C-1 off Saint-Augustin

Date & Time: Jan 4, 1999 at 0859 LT
Type of aircraft:
Operator:
Registration:
C-FGOI
Survivors:
Yes
Schedule:
Lourdes-de-Blanc-Sablon – Saint-Augustin
MSN:
UC-085
YOM:
1989
Flight number:
RH1707
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Copilot / Total flying hours:
4000
Copilot / Total hours on type:
500
Circumstances:
The Régionnair Inc. Beechcraft 1900C, serial number UC-85, with two pilots and 10 passengers on board, was making an instrument flight rules (IFR) flight between Lourdes-de-Blanc-Sablon, Quebec, and Saint-Augustin, Quebec. Just before initiation of descent, the radiotelephone operator of the Saint-Augustin Airport UNICOM (private advisory service) station informed the crew that the ceiling was 300 feet, visibility a quarter of a mile in snow flurries, and the winds from the southeast at 15 knots gusting to 20 knots. The crew made the LOC/DME (localizer transmitter / distance-measuring equipment) non-precision approach for runway 20. The approach proceeded normally until the minimum descent altitude (MDA). When the first officer reported sighting the ground beneath the aircraft, the captain decided to continue descending below the MDA. Thirty-five seconds later, the ground proximity warning system (GPWS) AMINIMUMS@ audible alarm sounded. Three seconds later, the aircraft flew into the frozen surface of the Saint-Augustin River. The occupants escaped the accident unharmed. The aircraft was heavily damaged.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.
Final Report:

Crash of an Antonov AN-32B in Kinshasa

Date & Time: Dec 31, 1998
Type of aircraft:
Operator:
Registration:
RA-48014
Flight Type:
Survivors:
Yes
MSN:
34 01
YOM:
1993
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Kinshasa-N'Djili Airport in heavy rain, the nose gear collapsed and the aircraft came to rest. There were no casualties but the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere during 1998.

Crash of an Ilyushin II-86 in Moscow

Date & Time: Dec 31, 1998
Type of aircraft:
Operator:
Registration:
RA-86080
Survivors:
Yes
MSN:
51483206051
YOM:
1986
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was withdrawn from use 2 July 1998 following a hard landing in Moscow. The mishap occurred prior to June 1998, exact date unknown. There were no casualties.

Crash of an Embraer ERJ-145 in Curitiba

Date & Time: Dec 28, 1998 at 0847 LT
Type of aircraft:
Operator:
Registration:
PT-SPE
Survivors:
Yes
Schedule:
Campinas - Curitiba
MSN:
145-032
YOM:
1997
Flight number:
SL310
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5200
Captain / Total hours on type:
100.00
Copilot / Total flying hours:
4700
Copilot / Total hours on type:
800
Circumstances:
On final approach to runway 15, after passing through the last cloud layer, the pilot-in-command realized he was too high on the glide. Rather than initiating a go-around procedure, the captain increased the rate of descent at 1,800 feet per minute and continued with a wrong approach configuration. The aircraft landed with a positive acceleration of 11 gm causing the fuselage to break in two after the wings. The crew continued the braking procedure and vacated the runway before stopping the aircraft on a taxiway. All 40 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- There was the participation of factors, with their own characteristics, that caused failures of attention, judgment and perceptual evaluation of distances and temporality. The qualitative training deficiency, the lack of cabin resource management and the low situational alert were significant contributing factors to the accident.
- PF has performed poorly in the use of the correct piloting technique in the combination of Speed x Ratio of Descent parameters.
- The instructor assigned by the company to supervise the acquisition of operational experience on route had not received specific instruction for the performance of this task. Technical and operational supervision was lacking.
- PF had good flight experience, but not in this type of aircraft. It was in the phase of acquiring operational experience in route. The inadequate action was also due to the little experience in the aircraft and in the circumstance of the operation, which required a quick correction close to the ground.
- The pilots did not adequately utilize the resources available in the cockpit for the proper operation of the aircraft. PF did not make the necessary corrections to modify the aircraft's trajectory, which was its assignment. The instructor (PNF), in turn, did not effectively correct or interfere with the PF flight, which would have been his responsibility since he was the supervisor of the operation. The pilots did not observe, yet, the technical-operational procedure foreseen in the Flight Operations Manual (MOV), regarding the GPWS warning. The crew did not observe that the warning determined an unsafe condition close to the touch. It was characterized an ineffective fulfillment of the tasks assigned to each crew member, besides the non-observance of the operational rules.
- On the IMC approach made, the PF varied the parameters, remaining high on the ramp. Upon reaching visual conditions, the PF increased the descent rate of the aircraft. The PNF, concerned with locating the runway, did not consider an inadequate PF correction.
- The PF, with the intention of reducing the drop ratio, did not apply correctly, in amplitude and in time, the power available in the engines. Near the touch, the PF increased the pitch angle, trying to reduce the drop ratio. Considering the low height (approximately 80 ft) and engine power (IDLE), the aircraft continued with a high rate of descent (approximately 1,800 ft/min), without the action taken by the PF altering its path. The PNF did not interfere in the application of the commands. Therefore, there was inadequate use of the aircraft commands by the crew members, in conditions for which they were qualified.
- The PF, even being alerted by the PNF about the low speed and high rate of descent, thought it was applying an adequate correction, however it kept the aircraft in an incompatible performance for landing. The PNF, despite having experience in flight and in the aircraft, showed a lack of knowledge of its limits regarding the point of irreversibility of an unsafe situation. The PNF was limited to alerting the PF about the situation, not guiding it on the correct way to make the corrections.
The PNF overestimated PF's capacity and did not take or try to take over the controls.
- The pilots were not aware of the maximum rate of descent during the touch for which the aircraft was certified, nor were they aware of the variation of that rate with respect to weight. The availability of the autopilot to the MDA could have minimized the ramp deviation observed.
Final Report:

Crash of an Antonov AN-32B in Medellín: 5 killed

Date & Time: Dec 22, 1998 at 0014 LT
Type of aircraft:
Operator:
Registration:
HK-3930X
Flight Type:
Survivors:
No
Schedule:
Bogotá – Medellín
MSN:
3309
YOM:
1993
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
5554
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
2017
Copilot / Total hours on type:
1000
Aircraft flight hours:
3106
Circumstances:
The aircraft departed Bogotá-El Dorado Airport on a cargo flight to Medellín, carrying two passengers, three crew members and a load of newspapers. On approach to Medellín-José María Córdova Airport, the crew encountered poor weather conditions and reduced visibility due to thick fog. On short final, the aircraft was too low, struck trees and crashed one km short of runway 36. The aircraft was totally destroyed upon impact and all five occupants were killed.
Probable cause:
Controlled flight into terrain after the crew decided to continue the approach in below minima weather conditions due to thick fog until the aircraft impacted terrain. The crew failed to initiate a go-around procedure to divert to a suitable terrain.
Final Report:

Crash of an Antonov AN-12BP in Saurimo: 1 killed

Date & Time: Dec 17, 1998
Type of aircraft:
Operator:
Registration:
S9-CAT
Flight Type:
Survivors:
Yes
Schedule:
Luanda - Saurimo
MSN:
6 34 45 03
YOM:
1973
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On final approach to Saurimo Airport, the captain initiated a go-around procedure after a vehicle entered the runway. The crew increased engine power but the aircraft continued to descend and struck the runway surface just past the threshold. Upon impact, the aircraft went out of control and came to rest, bursting into flames. The navigator was killed and nine other occupants were injured.