Crash of a Harbin Yunsunji Y-12-II in Jomsom

Date & Time: Nov 8, 1993
Type of aircraft:
Operator:
Registration:
9N-ACS
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
0044
YOM:
1991
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 24, the aircraft was unable to stop within the remaining distance. It overran, went down an embankment and came to rest in the Gandaki River with its right wing torn off. All 19 occupants were rescued, among them both pilots and three passengers were injured.
Probable cause:
For unknown reasons, the crew landed 240 metres past the runway 24 threshold (runway 24 is 600 metres long).

Crash of a Cessna 421B Golden Eagle II in Greensburg: 5 killed

Date & Time: Nov 6, 1993 at 0851 LT
Registration:
N41010
Survivors:
No
Schedule:
Pontiac - Greensburg
MSN:
421B-0569
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2900
Captain / Total hours on type:
225.00
Aircraft flight hours:
2600
Circumstances:
The pilot reported ice accretion en route to his destination and subsequently requested, and received a lower altitude from ATC. The flight was issued a clearance for a VOR-A approach to the Greensburg Airport, and was observed by a witness north of the airport to fly for a short period down runway 18 about seven feet above the runway. The witness then observed the airplane began to climb and fly off in a southerly direction. Other witnesses saw the airplane flying in the vicinity of the airport beneath an overcast ceiling estimated between 300 feet and 1,000 feet AGL. One witness, located about two miles south of the airport, saw the airplane turn sharply left, drop nose low, recover, drop nose low, and then descend from sight behind trees. Investigators and rescue personnel discovered a large amount of ice debris along the flight path and outside the fire ring at the crash site.
Probable cause:
An inadvertent stall by the pilot in command. Factors associated with the accident are the icing conditions and low ceilings.
Final Report:

Crash of a Boeing 747-409 in Hong Kong

Date & Time: Nov 4, 1993 at 1136 LT
Type of aircraft:
Operator:
Registration:
B-165
Survivors:
Yes
Schedule:
Taipei - Hong Kong
MSN:
24313
YOM:
1993
Flight number:
CI605
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
274
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12469
Captain / Total hours on type:
3559.00
Copilot / Total flying hours:
5705
Copilot / Total hours on type:
908
Aircraft flight hours:
1969
Aircraft flight cycles:
359
Circumstances:
China Airlines' scheduled passenger flight CAL605 departed Taipei (TPE), Taiwan at 02:20 for the 75-minute flight to Hong Kong-Kai Tak (HKG). The departure and cruise phases were uneventful. During the cruise the commander briefed the co-pilot on the approach to Hong Kong using the airline's own approach briefing proforma as a checklist for the topics to cover. The briefing included the runway-in-use, navigation aids, decision height, crosswind limit and missed approach procedure. He paid particular attention to the crosswind and stated that, should they encounter any problem during the approach, they would go-around and execute the standard missed approach procedure. The commander did not discuss with the co-pilot the autobrake setting, the reverse thrust power setting or their actions in the event of a windshear warning from the Ground Proximity Warning System (GPWS). Weather reports indicated strong gusty wind conditions, rain and windshear. On establishing radio contact with Hong Kong Approach Control at 03:17, the crew were given radar control service to intercept the IGS approach to runway 13 which is offset from the extended runway centreline by 47°. After intercepting the IGS localiser beam, the pilots changed frequency to Hong Kong Tower and were informed by the AMC that the visibility had decreased to 5 kilometres in rain and the mean wind speed had increased to 22 kt. Two minutes before clearing CAL605 to land, the air traffic controller advised the crew that the wind was 070/25 kt and to expect windshear turning short final. During the approach the pilots completed the landing checklist for a flaps 30 landing with the autobrakes controller selected to position '2' and the spoilers armed. The reference airspeed (Vref) at the landing weight was 141 kt; to that speed the commander added half the reported surface wind to give a target airspeed for the final approach of 153 kt. Rain and significant turbulence were encountered on the IGS approach and both pilots activated their windscreen wipers. At 1,500 feet altitude the commander noted that the wind speed computed by the Flight Management Computer (FMC) was about 50 kt. At 1,100 feet he disconnected the autopilots and commenced manual control of the flightpath. A few seconds later at 1,000 feet he disconnected the autothrottle system because he was dissatisfied with its speed holding performance. From that time onwards he controlled the thrust levers with his right hand and the control wheel with his left hand. Shortly afterwards the commander had difficulty in reading the reference airspeed on his electronic Primary Flying Display (PFD) because of an obscure anomaly, but this was rectified by the co-pilot who re-entered the reference airspeed of 141 kt into the FMC. Shortly before the aircraft started the visual right turn onto short final, the commander saw an amber 'WINDSHEAR' warning on his PFD. A few seconds later, just after the start of the finals turn, the ground proximity warning system (GPWS) gave an aural warning of "GLIDESLOPE" which would normally indicate that the aircraft was significantly below the IGS glidepath. One second later the aural warning changed to "WINDSHEAR" and the word was repeated twice. At the same time both pilots saw the word 'WINDSHEAR' displayed in red letters on their PFDs. Abeam the Checkerboard the commander was aware of uncommanded yawing and pitch oscillations. He continued the finals turn without speaking whilst the co-pilot called deviations from the target airspeed in terms of plus and minus figures related to 153 kt. At the conclusion of the turn both pilots were aware that the aircraft had descended below the optimum flight path indicated by the optical Precision Approach Path Indicator (PAPI) system. The air traffic controller watched the final approach and landing of the aircraft. It appeared to be on or close to the normal glidepath as it passed abeam the tower and then touched down gently on the runway just beyond the fixed distance marks (which were 300 metres beyond the threshold) but within the normal touchdown zone. The controller was unable to see the aircraft in detail after touchdown because of water spray thrown up by it but he watched its progress on the Surface Movement Radar and noted that it was fast as it passed the penultimate exit at A11. At that time he also observed a marked increase in the spray of water from the aircraft and it began to decelerate more effectively. The commander stated that the touchdown was gentle and in a near wings level attitude. Neither pilot checked that the speed brake lever, which was 'ARMED' during the approach, had moved to the 'UP' position on touchdown. A few seconds after touchdown, when the nose wheel had been lowered onto the runway, the co-pilot took hold of the control column with both hands in order to apply roll control to oppose the crosswind from the left. The aircraft then began an undesired roll to the left. Immediately the commander instructed the co-pilot to reduce the amount of applied into-wind roll control. At the same time he physically assisted the co-pilot to correct the aircraft's roll attitude. Shortly after successful corrective action the aircraft again rolled to the left and the commander intervened once more by reducing the amount of left roll control wheel rotation. During the period of unwanted rolling, which lasted about seven seconds, the aircraft remained on the runway with at least the left body and wing landing gears in contact with the surface. After satisfactory aerodynamic control was regained, the co-pilot noticed a message on the Engine Indicating and Crew Alerting System (EICAS) display showing that the autobrake system had disarmed. He informed the commander that they had lost autobrakes and then reminded him that reverse thrust was not selected. At almost the same moment the commander selected reverse thrust on all engines and applied firm wheel braking using his foot pedals. As the aircraft passed abeam the high speed exit taxiway (A11), the commander saw the end of the runway approaching. At that point both he and the co-pilot perceived that the distance remaining in which to stop the aircraft might be insufficient. At about the same time the co-pilot also began to press hard on his foot pedals. As the aircraft approached the end of the paved surface the commander turned the aircraft to the left using both rudder pedal and nose wheel steering tiller inputs. The aircraft ran off the end of the runway to the left of the centreline. The nose and right wing dropped over the sea wall and the aircraft entered the sea creating a very large plume of water which was observed from the control tower, some 3.5 km to the northwest. The controller immediately activated the crash alarm and the Airport Fire Contingent, which had been on standby because of the strong winds, responded very rapidly in their fire vehicles and fire boats. Other vessels in the vicinity also provided prompt assistance. After the aircraft had settled in the water, the commander operated the engine fuel cut-off switches and the co-pilot operated all the fire handles. The commander attempted to speak to the cabin crew using the interphone system but it was not working. The senior cabin crew member arrived on the flight deck as the commander was leaving his seat to proceed aft. The instruction to initiate evacuation through the main deck doors was then issued by the commander and supervised by the senior cabin crew member from the main deck. Ten passengers were injured, one seriously.
Probable cause:
The accident was the consequence of the combination of the following factors:
- The commander deviated from the normal landing roll procedure in that he inadvertently advanced the thrust levers when he should have selected reverse thrust.
- The commander diminished the co-pilot's ability to monitor rollout progress and proper autobrake operation by instructing him to perform a non-standard duty and by keeping him ill-informed about his own intentions.
- The copilot lacked the necessary skill and experience to control the aircraft during the landing rollout in strong, gusty crosswind conditions.
- The absence of a clearly defined crosswind landing technique in China Airline's Operations Manual deprived the pilots of adequate guidance on operations in difficult weather conditions.
Final Report:

Crash of a Convair CV-440 Metropolitan in El Triunfo

Date & Time: Nov 3, 1993
Operator:
Registration:
CP-2212
Flight Type:
Survivors:
Yes
Schedule:
Santa Rosa de Yacuma - La Paz
MSN:
330
YOM:
1956
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Six minutes after takeoff from Santa Rosa de Yacuma Airport, en route to La Paz, the flight engineer informed the captain that the left engine caught fire. The crew shut down the engine and feathered its propeller. The captain decided to attempt an emergency landing on an abandoned airfield located in El Triunfo, about 24 km north of Santa Rosa de Yacuma Airport. After landing, the aircraft rolled for about 100 metres when the left main gear collapsed. The aircraft veered to the left and rolled for few dozen metres before coming to rest, bursting into flames. All three crew members escaped uninjured and the fire partially destroyed the left part of the aircraft.
Probable cause:
Fire of the left engine after takeoff for unknown reasons.

Crash of a Beriev BE-12NKh off Yuzhno-Kurilsk

Date & Time: Oct 31, 1993
Type of aircraft:
Registration:
82 yellow
Survivors:
Yes
Schedule:
Yuzhno-Sakhalinsk - Yuzhno-Kurilsk
MSN:
9 6 017 02
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Yuzhno-Kurilsk, the crew realized that the sea was relatively rough with waves of 1,5 meter. Despite the situation, the crew decided to land in the bay. After touchdown, the right float was torn off and the aircraft rolled to the right and came to rest 120 metres offshore, partially submerged. All 20 occupants were rescued while a rescuer died from hypothermia. The aircraft partially sank as the fuselage was cut in several places after suffering chocks with water.

Crash of a De Havilland DHC-6 Twin Otter 300 in Namsos: 6 killed

Date & Time: Oct 27, 1993 at 1916 LT
Operator:
Registration:
LN-BNM
Survivors:
Yes
Schedule:
Trondheim - Namsos
MSN:
408
YOM:
1974
Flight number:
WF744
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
4835
Captain / Total hours on type:
1998.00
Copilot / Total flying hours:
6354
Copilot / Total hours on type:
1365
Aircraft flight hours:
40453
Circumstances:
On approach to Namsos Airport by night, the crew encountered poor visibility due to rain falls. In below weather minima, the crew descended below the minimum safe altitude until the aircraft struck the ground and crashed in a swampy area located about 6 km short of runway. The aircraft was destroyed on impact and six occupants including both pilots were killed. All 13 other occupants were injured.
Probable cause:
The accident was the consequence of a controlled flight into terrain. The following findings were reported:
- The company had failed to implement a standardized concept of aircraft operation that the pilots fully respected and lived by;
- The approach briefing was not not fully implemented in accordance with the rules. There were deficiencies in:
- "Call outs" during the approach
- Descent rate (feet/min) during "FAF inbound"
- Timing "outbound" from the IAF and the time from FAF to MAPt;
- The crew did not execute the "base turn" at the scheduled time, with the consequence that the plane ended up about 14 NM from the airport;
- The Pilot Flying ended the approach with reference to aircraft instruments and continued on a visual approach in the dark without visual reference to the underlying terrain. During this part of the approach the aircraft's position was not positively checked using any available navigational aids;
- Both crew members had in all likelihood most of the attention out of the cockpit at the airport after the Pilot Not Flying announced that he had it in sight;
- The crew was never aware of how close they were the underlying terrain;
- The last part of the descent from about 500 feet indicated altitude to 392 feet can be caused by inattention to the fact that the plane may have been a little out of trim after the descent;
- Crew Cooperation during the approach was not in accordance with with the CRM concept and seems to have ceased completely after the Pilot Not Flying called "field in sight";
- Before the accident the company had not succeeded well enough with the introduction of standardization and internal control/quality assurance. This was essentially because the management had not placed enough emphasis on awareness and motivate employees;
- The self-control system described in the airline operations manual and the parts of the quality system, was not incorporated in the organization and served as poor safety governing elements;
- Neither the Norwegian CAA nor the company had defined what visual reference to terrain is, what sufficient visual references are and what the references must be in relation to a moving aircraft.
Final Report:

Crash of a McDonnell Douglas MD-82 in Fuzhou: 2 killed

Date & Time: Oct 26, 1993 at 1304 LT
Type of aircraft:
Operator:
Registration:
B-2103
Survivors:
Yes
Schedule:
Shenzhen - Fuzhou
MSN:
49355
YOM:
1985
Flight number:
MU5398
Location:
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The descent to Fuzhou Airport was completed in poor weather conditions with limited visibility due to heavy rain falls. On short final, the aircraft was too high and about 350 metres to the right of the extended centerline. The captain realized he could not land in such conditions so, at a height of 20 metres, he decided to initiate a go-around procedure, increased engine power and retracted the flaps. The aircraft continued to descend so the crew finally decided to land. The aircraft touched down 1,983 metres past the runway threshold. On a wet runway surface, it was unable to stop within the remaining distance, overran, lost its undercarriage and came to rest in a swamp located 385 metres past the runway end, broken in three. Two passengers were killed while 25 others were injured.
Probable cause:
Wrong approach configuration on part of the flying crew. The braking coefficient was reduced because the runway surface was wet. The crew failed to initiate a go-around procedure earlier.

Crash of a McDonnell Douglas MD-82 in Kaohsiung

Date & Time: Oct 25, 1993 at 1159 LT
Type of aircraft:
Operator:
Registration:
B-28003
Survivors:
Yes
Schedule:
Kaohsiung - Taipei
MSN:
53065
YOM:
1991
Flight number:
FE118
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
152
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Kaohsiung-Hsiao Kang Airport, while climbing to a height of 600 feet, the left engine failed. The crew declared an emergency and was cleared to return. On approach, the aircraft was unstable and too high on the glide. It landed too far down the runway, about 4,000 feet past the runway threshold. Unable to stop within the remaining distance, the aircraft overran, collided with a drainage ditch, lost its undercarriage and eventually came to rest against a concrete wall. All 160 occupants were evacuated, among them four passengers were slightly injured.
Probable cause:
The fan cowl on the left engine separated during initial climb.

Crash of an Embraer EMB-110P2 Bandeirante in Bangkok

Date & Time: Oct 25, 1993
Operator:
Registration:
HS-SKL
Flight Type:
Survivors:
Yes
Schedule:
Bangkok - Bangkok
MSN:
110-229
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a local post maintenance test flight at Bangkok-Don Mueang Airport. After takeoff, while in initial climb, the crew encountered technical problems with the left main gear. After being cleared by ATC, the crew decided to return for an emergency landing and made a turn then completed a belly landing. The aircraft came to rest on the main runway and was damaged beyond repair. Both pilots escaped uninjured.
Probable cause:
It was determined that a an element of the left main landing gear strut failed during initial climb, causing the loss of several elements of the landing gear.

Crash of a Piper PA-46-310P Malibu on Mt Balmfluechöpfli: 1 killed

Date & Time: Oct 24, 1993 at 1440 LT
Operator:
Registration:
HB-PMA
Flight Type:
Survivors:
Yes
Site:
Schedule:
Cannes - Grenchen
MSN:
46-08132
YOM:
1988
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1181
Captain / Total hours on type:
440.00
Aircraft flight hours:
922
Circumstances:
After passing over the Alps and a layer of stratus over the Plateau, the pilot reached the Willisau VOR where he was cleared to initiate an IFR approach to Grenchen Airport runway 25. He completed a standard turn then followed the 290° radial instead of the published 280° radial. When the DME system indicated 7 NM, the pilot realized he was too far from the normal approach track, disengaged the automatic pilot system and elected to gain altitude. In a flaps down/gear down configuration, the aircraft failed to gain sufficient height and struck, in poor visibility due to thick fog, the wooded slope of Mt Balmfluechöpfli (1,289 metres high) located about 12 km northeast of Grenchen Airport. The aircraft disintegrated on impact and the pilot was killed. The female passenger, slightly injured as she was seating in the seat opposite to the direction of flight, was able to walk away to ask for help.
Probable cause:
The accident was the consequence of the following factors:
- Selection of the radial 290° and engagement thereon instead of the published 280° radial,
- Inappropriate NAV setting,
- Too late and inconsistent throttle reset,
- Difficult IFR approach procedure without radar monitoring of the followed route,
- Too high speed on approach.
Final Report: