Crash of an Embraer EMB-110EJ Bandeirante in São Gabriel da Cachoeira

Date & Time: May 7, 1994 at 1248 LT
Operator:
Registration:
PT-GJW
Survivors:
Yes
Schedule:
Santa Isabel do Rio Negro – São Gabriel da Cachoeira
MSN:
110-072
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
5180.00
Circumstances:
The crew encountered poor weather conditions on approach to São Gabriel da Cachoeira Airport with low visibility due to fog. On short final, the crew failed to realize his altitude was insufficient when the aircraft collided with trees and crashed few hundred metres short of runway. All 16 occupants were injured, three seriously. The aircraft was destroyed.
Probable cause:
Contributing factors
a. Human Factor
(1). Psychological Aspect
It contributed, since the pilot in command adopted an improvisational attitude through the adoption of unforeseen procedures in the face of the insistence on landing, despite the weather conditions present. A likely channeling of attention to external references may have contributed to the loss of operational performance, leading to the loss of the maintenance condition of the basic flight parameters.
(2). Physiological Aspect
Undetermined since the absence of interference from toxicological factors was not effectively verified.
b. Material Factor
Didn't contribute.
c. Operational Factor
(1). Deficient Instruction
It contributed since there was no periodic simulator training and also no cockpit resource management (CRM) training.
(2). Deficient Supervision
It contributed since there was no adequate monitoring of the circumstances of operation by the Company's operations sector and, also, there were no defined and clear rules and specific operating routines that adequately addressed the various aspects of the operation.
(3). Little Flight or Aircraft Experience
It contributed because of the small experience in the aircraft by the copilot.
(4). Influence of the Environment
It contributed since visibility was limited at the time of the accident.
(5). Deficient Cockpit Coordination
Contributed since there was no briefing to the accomplishment of the descent procedure by instruments, the copilot did not follow the execution of the procedures after the critical point since he concentrated his attention to the search of external references, thus abandoning the monitoring of the flight parameters.
(6). Disabled Infrastructure
Indetermined since the influence of the low accuracy of the NDB on the heading lags occurred in the descent procedure was not perfectly established and no effective test was performed.
(7). Poor Planning
It contributed because there was no briefing in the procedure of descent by instrument and approach lost.
(8). Deficient discipline of Flight
The pilot therefore continued the flight, without visibility, at an altitude below the minimum for this operating condition.
(9). Adverse Weather Conditions
It contributed as the prevailing weather conditions were marginal, with the aerodrome closed for IFR operation.
Final Report:

Crash of a Tupolev TU-134A-3 in Arkhangelsk

Date & Time: May 7, 1994 at 1242 LT
Type of aircraft:
Operator:
Registration:
RA-65976
Survivors:
Yes
Schedule:
Moscow - Arkhangelsk
MSN:
3 35 20 07
YOM:
1973
Flight number:
SU2315
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
56
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
33606
Aircraft flight cycles:
21071
Circumstances:
On approach to Arkhangelsk-Talagi, the crew encountered technical problems with the landing gear that could not be lowered. Several manual attempts were made and finally, only the right main gear remained stuck in its wheel well. The captain decided to land in such configuration. After touchdown, the aircraft slid on the ground then veered off runway and came to rest in a grassy area. All 62 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The right main gear could not be lowered because of a breakage of the filling connection of the hydraulic tank due to metal fatigue while the aircraft was taxiing at Moscow-Sheremetyevo Airport. The fitting was blown out under pressure and damaged hydraulic lines, causing a hydraulic fluid leak and the oil pressure to drop.

Crash of a Beechcraft 200 King Air in Kinshasa: 9 killed

Date & Time: May 7, 1994 at 0045 LT
Operator:
Registration:
9Q-CTG
Survivors:
No
Schedule:
Gbadolite - Kinshasa
MSN:
BB-629
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Following an uneventful flight from Gbadolite, the crew started a night approach to Kinshasa-N'Djili Airport. On short final, the crew failed to realize his altitude was insufficient when the aircraft struck trees and crashed 3 km short of runway. The aircraft was destroyed and all nine occupants were killed, among them Mpinga Kasenda, Minister of Foreign Affairs by the Zaire Government, Patrice Mandoko Bingoto, General Manager of SNEL (Société Nationale d’Électricité) and two Tunisian diplomats.

Crash of a Cessna 208 Caravan I in El Rosal: 8 killed

Date & Time: Apr 29, 1994 at 1427 LT
Type of aircraft:
Registration:
HK-3479
Survivors:
Yes
Site:
Schedule:
Furatena – Quipama – Boyaca – Bogotá
MSN:
208-0143
YOM:
1989
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
While descending to Bogotá-El Dorado Airport, the single engine aircraft struck the slope of a mountain located near El Rosal, about 19 km northwest of the airport. A passenger was seriously injured while eight other occupants were killed. For unknown reasons, the pilot was completing the approach at an unsafe altitude.

Crash of a Piper PA-31-350 Navajo Chieftain in Stratford: 8 killed

Date & Time: Apr 27, 1994 at 2256 LT
Operator:
Registration:
N990RA
Survivors:
Yes
Schedule:
Atlantic City - Stratford
MSN:
31-7405417
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
3500
Captain / Total hours on type:
527.00
Circumstances:
The captain had ILS glideslope data available during the approach but did not fly the ILS glideslope. The partial obscuration of the airport environment, due to ground fog, contributed to the captain's failure to recognize that the airplane was high on both his approach and landing. The destruction of the airplane and the resulting occupant injuries were a direct result of the collision with the blast fence. FAA interaction and communication with local communities, although persistent, were unsuccessful in gaining support for runway safety area improvements and for the installation of approach lighting for runway 6. The passenger seats had been improperly assembled using unapproved parts, and seat belts had been installed incorrectly.
Probable cause:
The failure of the captain to use the available ILS glideslope, his failure to execute a go-around when conditions were not suitable for landing, and his failure to land the airplane at a point
sufficient to allow for a safe stopping distance; the fatalities were caused by the presence of the non frangible blast fence and the absence of a safety area at the end of the runway.
Final Report:

Crash of a Boeing 727-44F in M'Banza Kongo: 7 killed

Date & Time: Apr 27, 1994 at 1610 LT
Type of aircraft:
Operator:
Registration:
S9-TAN
Flight Type:
Survivors:
Yes
Schedule:
Luanda - M'Banza Kongo
MSN:
18893
YOM:
1965
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
On final approach to M'Banza Kongo Airport, the aircraft was too low and struck the ground 3,200 metres short of runway. It reached a little altitude then descended again and struck the ground a second time two metres short of runway. On impact, the left main gear struck a drainage ditch and was torn off. The aircraft slid on the ground, veered to the right when the right wing struck a bus. All three crew members escaped with minor injuries while seven people in the bus were killed.
Probable cause:
The M'Banza Kongo runway is relatively short and the crew must complete a low approach to be able to land as early as possible. Here, the crew completed a too low approach, causing the aircraft to struck the ground twice before runway threshold.

Crash of an Airbus A300-622R in Nagoya: 264 killed

Date & Time: Apr 26, 1994 at 2015 LT
Type of aircraft:
Operator:
Registration:
B-1816
Survivors:
Yes
Schedule:
Taipei - Nagoya
MSN:
580
YOM:
1990
Flight number:
CI140
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
256
Pax fatalities:
Other fatalities:
Total fatalities:
264
Captain / Total flying hours:
8340
Captain / Total hours on type:
1350.00
Copilot / Total flying hours:
1624
Copilot / Total hours on type:
1033
Aircraft flight hours:
8550
Aircraft flight cycles:
3910
Circumstances:
China Airlines' Flight 140 (from Taipei International Airport to Nagoya Airport), B-1816, took off from Taipei International Airport at 0853 UTC (1753 JST) on April 26, 1994 (hereinafter all times shown are Coordinated Universal Time, unless otherwise specified), canying a total of 271 persons consisting of 2 flight crew members, 13 cabin crew members and 256 passengers (including 2 infants). The flight plan of the aircraft, which had been filed to the Taiwanese civil aviation authorities, Zhongzheng International Airport Office, was as follows:
Flight rule: IFR, Aerodrome of departure: Taipei International Airport, Destination Aerodrome: Nagoya Airport, Cruising speed: 465 knots, Level: FL330, Route: A1 SUCJAKAL-KE-SIV-XMC, total estimated enroute time: 2 hours and 18 minutes, Alternate Aerodrome: Tokyo International Airport.
DFDR shows that the aircraft reached FL330 about 0914 and continued its course toward Nagoya Airport in accordance with its flight plan.
DFDR and CVR show that its flight history during approximately 30 minutes prior to the accident progressed as follows:
The aircraft which was controlled by the FIO, while cruising at FL330 was cleared at 1047:35 to descend to FL210 by the Tokyo Area Control Center and commenced descent. For about 25 minutes from a few minutes before the aircraft began its descent, the CAP briefed the F/O on approach and landing.
At 1058:18, communication was established with Nagoya Approach Control. The aircraft began to descend and decreased its speed gradually, in accordance with the clearances given by Approach Control.
At 1104:03, the aircraft was instructed by Nagoya Approach control to make a left turn to a heading of 010". Later, at 1107:14, the aircraft was cleared for ILS approach to Runway 34 and was instructed to contact Nagoya Tower. After the aircraft took off from Taipei International Airport, from 0854 when the aircraft had passed 1,000 feet pressure altitude, AP No.2 was engaged during climb, cruise and descent.
At 1107:22, when the aircraft was in the initial phase of approach to Nagoya airport, AP No. 1 was also engaged. Later, at 1111:36, both AP No. 1 and 2 were disengaged by the FIO. The aircraft passed the outer marker at 1112:19, and at 1113:39, received landing clearance from Nagoya Tower. At this time, the aircraft was reported of winds 290 degrees at 6 knots. Under manual control, the aircraft continued normal LS approach.
At 1114:05, however, while crossing approximately 1,070 feet pressure altitude, the F/O inadvertently triggered the GO lever. As a result the aircraft shifted into GO AROUND mode leading to an increase in thrust. The CAP cautioned the FIO that he had triggered the GO lever and instructed him, saying "disengage it". The aircraft leveled off for about 15 seconds at approximately 1,040 feet pressure altitude (at a point some 5.5 km from the Runway). The CAP instructed the F/O to correct the descent path which had become too high. The F/O acknowledged this. Following the instruction, the F/O applied nose down elevator input to adjust its descent path, and consequently the aircraft gradually regained its normal glide path. During this period, the CAP cautioned to the FIO twice that the aircraft was in GO AROUND Mode.
At 1114: 18, both AP No.2 and No. 1 were engaged almost simultaneously when the aircraft was flying at approximately 1,040 feet pressure altitude, a point 1.2 dots above the glide slope. Both APs were used for the next 30 seconds. There is no definite record in the CVR of either the crew expressing their intention or calling out to use the AP. For approximately 18 seconds after the AP was engaged, the THS gradually moved from -5.3" to -12.3", which is close to the maximum nose-up limit. The THS remained at -12.3" until 1115: 1 1. During this period, the elevator was continually moved in the nose-down direction. In this condition, the aircraft continued its approach, and at 1115:02, when it was passing about 510 feet pressure altitude (at a point approximately 1.8 km from the runway), the CAP, who had been informed by the FIO that the THR had been latched, told the FIO that he would take over the controls. Around this time, the THR levers had moved forward greatly, increasing EPR from about 1.0 to more than 1.5. Immediately afterwards, however, the THR levers were retarded, decreasing EPR to 1.3. In addition, the elevator was moved close to its nose-down limit when the CAP took the controls.
At 1115:11, immediately after the CAP called out "Go lever", the THR levers were moved forward greatly once again, increasing EPR to more than 1.6. The aircraft therefore began to climb steeply. The F/O reported to Nagoya Tower that the aircraft would go around, and Nagoya Tower acknowledged this. The aircraft started climbing steeply, AOA increased sharply and CAS decreased rapidly. During this period, the TI-IS decreased from -12.3" to -7.4", and SLATS/FLAPS were retracted from 30/40 to 15/15 after the F/O reported "Go Around to Nagoya Tower.
At 1115:17, the GPWS activated Mode 5 warning "Glide Slope" once, and at 1115:25, the stall warning sounded for approximately 2 seconds.
At 1115:31, after reaching about 1,730 feet pressure altitude (about 1,790 feet radio altitude), the aircraft lowered its nose and began to dive.
At 1115:37, the GPWS activated Mode 2 warning "Terrain, Terrain" once, and the stall warning sounded from 1115:40 to the time of crash.
At about 1115:45, the aircraft crashed into the landing zone close to the El taxiway. The accident occurred within the landing zone approximately 110 meters east-northeast of the center of the Runway 34 end at Nagoya Airport. It occurred at about 1115:45. Seven passengers were seriously injured and all 264 other occupants were killed.
Probable cause:
While the aircraft was making an ILS approach to Runway 34 of Nagoya Airport, under manual control by the F/O, the F/O inadvertently activated the GO lever, which changed the FD (Flight Director) to GO AROUND mode and caused a thrust increase. This made the aircraft deviate above its normal glide path. The APs were subsequently engaged, with GO AROUND mode still engaged. Under these conditions the FIO continued pushing the control wheel in accordance with the CAP'S instructions. As a result of this, the THS (Horizontal Stabilizer) moved to its full nose-up position and caused an abnormal out-of-trim situation. The crew continued approach, unaware of the abnormal situation. The AOA increased. The Alpha Floor function was activated and the pitch angle increased. It is considered that, at this time, the CAP (who had now taken the controls), judged that landing would be difficult and opted for go-around. The aircraft began to climb steeply with a high pitch angle attitude. The CAP and the FIO did not carry out an effective recovery operation, and the aircraft stalled and crashed.
The AAIC determined that the following factors, as a chain or a combination thereof, caused the accident:
1. The F/O inadvertently triggered the Go lever. It is considered that the design of the GO lever contributed to it: normal operation of the thrust lever allows the possibility of an inadvertent triggering of the GO lever.
2. The crew engaged the APs while GO AROUND mode was still engaged, and continued approach.
3. The F/O continued pushing the control wheel in accordance with the CAP'S instructions, despite its strong resistive force, in order to continue the approach.
4. The movement of the THS conflicted with that of the elevators, causing an abnormal out-of-trim situation.
5. There was no warning and recognition function to alert the crew directly and actively to the onset of the abnormal out-of-trim condition.
6. The CAP and FIO did not sufficiently understand the FD mode change and the AP override function. It is considered that unclear descriptions of the AFS (Automatic Flight System) in the FCOM (Flight Crew Operating Manual) prepared by the aircraft manufacturer contributed to this.
7. The CAP'S judgment of the flight situation while continuing approach was inadequate, control take-over was delayed, and appropriate actions were not taken.
8. The Alpha-Floor function was activated; this was incompatible with the abnormal out-of-trim situation, and generated a large pitch-up moment. This narrowed the range of selection for recovery operations and reduced the time allowance for such operations.
9. The CAP'S and F/O's awareness of the flight conditions, after the PIC took over the controls and during their recovery operation, was inadequate respectively.
10. Crew coordination between the CAP and the FiO was inadequate.
11. The modification prescribed in Service Bulletin SB A300-22-6021 had not been incorporated into the aircraft.
12. The aircraft manufacturer did not categorise the SB A300-22-602 1 as "Mandatory", which would have given it the highest priority. The airworthiness authority of the nation of design and manufacture did not issue promptly an airworthiness directive pertaining to implementation of the above SB.
Final Report:

Crash of a Cessna 208A Caravan in Jacareacanga: 2 killed

Date & Time: Apr 26, 1994 at 0740 LT
Type of aircraft:
Operator:
Registration:
PT-OGI
Flight Type:
Survivors:
No
Schedule:
Itaituba - Jacareacanga
MSN:
208-0039
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6000
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
350
Circumstances:
Five minutes after takeoff from Itaituba Airport, the crew was informed about weather conditions at destination with ceiling at ground and a visibility less than 300 metres which means that the conditions were below minimums. Upon arrival, the crew was unable to establish a visual contact with the airport and decided to circle for weather improvement. Few minutes later, the single engine aircraft crashed near the airport, killing both pilots.
Probable cause:
The accident was the consequence of the following factors:
1) Adverse Weather Conditions - Contributed
Weather conditions were unfavorable at the destination location for visual flight. There was a layer of fog near the forest.
2) Poor Instruction - Contributed
The Commander was not qualified to fly that type of aircraft and was not instrument cleared.
3) Disabled Judge - Contributed
The pilots continued the flight, even knowing the adverse weather conditions at their destination.
4) Flight Indiscipline - Contributed
One of the pilots was not qualified to fly that aircraft and, in addition, there was intentional disobedience to the air traffic rules and regulations, regarding the non observance of the minimum IFR flight level in the industry.
5) Disabled Oversight - Contributed
There was poor oversight of the responsible company by letting an unqualified pilot operate the aircraft.
6) Weak Cabin Coordination - Contributed
IFR flight without complying with IMA 100-12 rules, conducted below the limits and outside the descent profile are indications that there was no planning/coordination in the operations performed in the cockpit.
Final Report:

Crash of a Cessna 402B in Malacca

Date & Time: Apr 15, 1994
Type of aircraft:
Operator:
Registration:
M27-07
Flight Type:
Survivors:
Yes
Schedule:
Malacca - Malacca
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew consisting of two trainee pilots and one instructor departed Malacca-Batu Berendam Airport in the morning on a local training flight. Seventeen minutes after takeoff, the crew was returning to his departure point. For unknown reasons, the twin engine aircraft landed hard and came to rest, bursting into flames. All three occupants evacuated safely while the aircraft was written off. It was reported that one of the two pilots under training was attached to the Cambodian Air Force.

Crash of a Piper PA-31-350 Navajo Chieftain in Elizabethton: 2 killed

Date & Time: Apr 7, 1994 at 0810 LT
Operator:
Registration:
N64LB
Flight Type:
Survivors:
No
Schedule:
Augusta - Elizabethton
MSN:
31-7852127
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7800
Aircraft flight hours:
2910
Circumstances:
The ATP and his passenger were en route to pick up a patient for transport to a VA hospital. The destination airport was uncontrolled, and VFR only. The pilot cancelled with ATC and reported the field in sight. The airport was reporting VFR conditions, but rising, mountainous terrain existed to the northeast, and local authorities reported that the top third of the mountain was obscured in clouds during the morning of the accident. After cancelling IFR, no subsequent radio calls were received from the flight, and the flight did not arrive at its destination. The wreckage was found several hours later near the crest of holston mountain, 1/2 mile east of the Holston mountain VOR. An examination of the wreckage indicated the aircraft impacted upsloping, wooded terrain, while at a climb angle of 8°. Disintegration of the wreckage was indicative of a high speed impact. No evidence of mechanical malfunction or failure was found during the examination of the wreckage. Both occupants were killed.
Probable cause:
The pilot's attempted VFR flight into imc conditions, and his failure to maintain a proper altitude over mountainous terrain. Factors were the clouds and obscuration at the accident site.
Final Report: