Landing (descent or approach)

The Sky Lease Cargo Boeing 747-412F aircraft (U.S. registration N908AR, serial number 28026) was conducting flight 4854 (KYE4854) from Chicago/O’Hare International Airport, Illinois, U.S., to Halifax/Stanfield International Airport, Nova Scotia, with 3 crew members, 1 passenger, and no cargo on board. The crew conducted the Runway 14 instrument landing system approach. When the aircraft was 1 minute and 21 seconds from the threshold, the crew realized that there was a tailwind; however, they did not recalculate the performance data to confirm that the landing distance available was still acceptable, likely because of the limited amount of time available before landing. The unexpected tailwind resulted in a greater landing distance required, but this distance did not exceed the length of the runway. The aircraft touched down firmly at approximately 0506 Atlantic Standard Time, during the hours of darkness. After the firm touchdown, for undetermined reasons, the engine No. 1 thrust lever was moved forward of the idle position, causing the speed brakes to retract and the autobrake system to disengage, increasing the distance required to bring the aircraft to a stop. In addition, the right crab angle (4.5°) on initial touchdown, combined with the crosswind component and asymmetric reverser selection, caused the aircraft to deviate to the right of the runway centreline. During the landing roll, the pilot monitoring’s attention was focused on the lateral drift and, as a result, the required callouts regarding the position of the deceleration devices were not made. Although manual brake application began 8 seconds after touchdown, maximum braking effort did not occur until 15 seconds later, when the aircraft was 800 feet from the end of the runway. At this position, it was not possible for the aircraft to stop on the runway and, 5 seconds later, the aircraft departed the end of the runway at a speed of 77 knots and came to a stop 270 m (885 feet) past the end. The aircraft struck the approach light stanchions and the localizer antenna array. The No. 2 engine detached from its pylon during the impact sequence and came to rest under the left horizontal stabilizer, causing a fire in the tail section following the impact. The emergency locator transmitter activated. Aircraft rescue and firefighting personnel responded. All 3 crew members received minor injuries and were taken to the hospital. The passenger was not injured. During the overrun, the aircraft crossed a significant drop of 2.8 m (9 feet) approximately 166 m (544 feet) past the end of the runway and was damaged beyond repair.

Following an uneventful flight from Ulan-Ude, the crew initiated the approach to Yakutsk-Platon Oyunsky Intl Airport Runway 23L. Due to work in progress, the runway 05R threshold was displaced by 1,150 metres, reducing the landing distance to 2,248 metres for the runway 23L on which the touchdown zone lighting system was unserviceable. On approach, the crew was informed by ATC that the friction coefficient was 0,45. The crew completed the landing on runway 23L with a slight tailwind component of 4 knots and started the braking procedure. Unable to stop within the remaining distance, the aircraft overran, entered the construction area and collided with the junction of a concrete section under reconstruction, causing both main landing gear to collapse (the left main gear was torn off). The aircraft slid for another 250 metres before coming to rest. All 92 occupants evacuated safely and the aircraft was damaged beyond repair.

The airplane was engaged in an exercise with a second Sudanese Air Force Antonov AN-32. After touchdown on runway 18, the crew started the braking procedure when the airplane was struck by the AN-32 from behind. After collision, both airplanes went out of control and came to rest on the runway edge. There were no casualties while both aircraft were destroyed. It appears that the AN-32 landed shortly after the AN-26 and was unable to stop in a timely manner.

The airplane was engaged in an exercise with a second Sudanese Air Force Antonov AN-32. After touchdown on runway 18, the crew started the braking procedure when the airplane was struck by the AN-32 from behind. After collision, both airplanes went out of control and came to rest on the runway edge. There were no casualties while both aircraft were destroyed. It appears that the AN-32 landed shortly after the AN-26 and was unable to stop in a timely manner.

On 28 September 2018, at 23:24:19 UTC2 (09:24 local time), a Boeing 737-8BK aircraft, registered P2-PXE (PXE), operated by Air Niugini Limited, was on a scheduled passenger flight number PX073, from Pohnpei to Chuuk, in the Federated States of Micronesia (FSM) when, during its final approach, the aircraft impacted the water of the Chuuk Lagoon, about 1,500 ft (460 m) short of the runway 04 threshold. The aircraft deflected across the water several times before it settled in the water and turned clockwise through 210 deg and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265°. The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot. An Aircraft Maintenance Engineer occupied the cockpit jump seat. The engineer videoed the final approach on his iPhone, which predominantly showed the cockpit instruments. Local boaters rescued 28 passengers and two cabin crew from the left over-wing exits. Two cabin crew, the two pilots and the engineer were rescued by local boaters from the forward door 1L. One life raft was launched from the left aft over-wing exit by cabin crew CC5 with the assistance of a passenger. The US Navy divers rescued six passengers and four cabin crew and the Load Master from the right aft over-wing exit. All injured passengers were evacuated from the left over-wing exits. One passenger was fatally injured, and local divers located his body in the aircraft three days after the accident. The Government of the Federated States of Micronesia commenced the investigation and on 14th February 2019 delegated the whole of the investigation to the PNG Accident Investigation Commission. The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations. The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)4 the aircraft was flown in Instrument Meteorological Conditions (IMC). The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The RNAV approach specified a flight path descent angle guide of 3º. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5º during the approach, with lateral over-controlling; the approach was unstabilised. The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope”. The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate”. The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap. Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway. The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM. The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected. The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC. The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI. The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:
• The aircraft had entered IMC;
• the approach was unstable;
• the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;
• the rate of descent high (more than 1,000 ft/min) and increasing;
• there were EGPWS Sink Rate and Glideslope aural alerts; and
• the EGPWS visual PULL UP warning message was displayed on the PFD.
The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs, standard phraseology and recommended practices. The investigation found that the Civil Aviation Safety Authority of PNG (CASA PNG) policy and procedures of accepting manuals rather than approving manuals, while in accordance with the Civil Aviation Rules requirements, placed a burden of responsibility on CASA PNG as the State Regulator to ensure accuracy and that safety standards are met. In accepting the Air Niugini manuals, CASA PNG did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors in the Air Niugini Operational, Technical, and Safety manuals as noted in this report and the associated Safety Recommendations. The report includes a number of recommendations made by the AIC, with the intention of enhancing the safety of flight (See Part 4 of this report). It is important to note that none of the safety deficiencies brought to the attention of Air Niugini caused the accident. However, in accordance with Annex 13 Standards, identified safety deficiencies and concerns must be raised with the persons or organisations best placed to take safety action. Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident. The AIC notes that Air Niugini Limited took prompt action to address all safety deficiencies identified by the AIC in the 12 Safety Recommendations issued to Air Niugini, in an average time of 23 days. The quickest safety action being taken by Air Niugini was in 6 days. The AIC has closed all 12 Safety Recommendations issued to Air Niugini Limited. One safety concern prompting an AIC Safety Recommendation was issued to Honeywell Aerospace and the US FAA. The safety deficiency/concern that prompted this Safety Recommendation may have been a contributing factor in this accident. The PNG AIC is in continued discussion with the US NTSB, Honeywell, Boeing and US FAA. This recommendation is the subject of ongoing research and the AIC Recommendation will remain ACTIVE pending the results of that research.

The flight crew was operating the business jet on an on-demand air taxi flight with passengers onboard. During landing at the destination airport, the cockpit voice recorder (CVR) recorded the sound of the airplane touching down followed by the pilot's and copilot's comments that the brakes were not operating. Air traffic controllers reported, and airport surveillance video confirmed, that the airplane touched down "normally" and the airplane's thrust reverser deployed but that the airplane continued down the runway without decelerating before overrunning the runway and impacting terrain. Postaccident examination of the airplane's brake system revealed discrepancies of the antiskid system that included a broken solder joint on the left-side inboard transducer and a reversal of the wiring on the right-side outboard transducer. It is likely that these discrepancies resulted in the normal braking system's failure to function during the landing. Before the accident flight, the airplane had been in long-term storage for several years and was in the process of undergoing maintenance to bring the airplane back to a serviceable condition, which in-part required the completion of several inspections, an overhaul of the landing gear, and the resolution of over 100 other unresolved discrepancies. The accident flight and four previous flights were all made with only a portion of this required maintenance having been completed and properly documented in the airplane's maintenance logs. A pilot, who had flown the airplane on four previous flights along with the accident pilot (who was acting as second-in-command during them), identified during those flights that the airplane's normal braking system was not operating when the airplane was traveling faster than 20 knots. He remedied the situation by configuring the airplane to use the emergency, rather than normal, braking system. That pilot reported this discrepancy to the operator's director of maintenance, and it is likely that maintenance personnel from the company subsequently added an "INOP" placard near the switch on the date of the accident. The label on the placard referenced the antiskid system, and the airplane's flight manual described that with the normal brake (or antiskid) system inoperative, the brake selector switch must be positioned to use the emergency braking system. Following the accident, the switch was found positioned with the normal braking system activated, and it is likely that the accident flight crew attempted to utilize the malfunctioning normal braking system during the landing. Additionally, the flight crew failed to properly recognize the failure and configure the airplane to utilize the emergency braking system, or utilize the parking brake, as described in the airplane's flight manual, in order to stop the airplane within the available runway.

The airline transport pilot of the multiengine airplane was cleared for the VOR approach. The weather at the airport was reported as 400 ft overcast with 4 miles visibility in drizzle. When the airplane failed to arrive at the airport as scheduled, a search was initiated, and the wreckage was located soon thereafter. Radar data indicated that the pilot was provided vectors to intercept the final approach course. The last radar return indicated that the airplane was at 2,200 ft and 8.1 miles from the runway threshold. It impacted terrain 3.5 miles from the runway threshold and left of the final approach course. According to the published approach procedure, the minimum descent altitude was 1,100 feet, which was 466 ft above airport elevation. Examination of the wreckage revealed that the airplane had impacted the tops of trees and descended at a 45° angle to ground contact; the airplane was destroyed by a postcrash fire, thus limiting the examination; however, no anomalies were observed that would have precluded normal operation. The landing gear was extended, and approach flaps had been set. Impact and fire damage precluded an examination of the flight and navigation instruments. Autopsy and toxicology of the pilot were not performed; therefore, whether a physiological issue may have contributed to the accident could not be determined. The location of the wreckage indicates that the pilot descended below the minimum descent altitude (MDA) for the approach; however, the reason for the pilot's descent below MDA could not be determined based on the available information.

The airplane departed Curitiba-Afonso Pena Airport at 1240LT on an executive flight to Foz do Iguaçu, carrying one passenger and two pilots. Following an uneventful flight, the crew started the descent to Foz do Iguaçu-Cataratas Airport. The aircraft was stabilized and landed on wet runway 32. After touchdown, the crew encountered difficulties to stop the aircraft that overran and came to rest into a ravine. All three occupants evacued safely and the aircraft was damaged beyond repair.

On approach to Yiral Airport in poor visibility due to fog, the twin engine aircraft descended too low, impacted the surface of the Yirol Lake and crashed about 2 km north of the airfield. The aircraft was destroyed upon impact and four occupants were rescued while 19 others were killed. A day later, one of the survivor died from his injuries. The three survivors are two children and a Italian doctor. The flight was completed on behalf of the Slaver Company based in Ukraine.

The private pilot of the multi-engine airplane was conducting an instrument approach during night visual meteorological conditions. About 1.3 nautical miles (nm) from the final approach fix, the right engine lost total power. The pilot continued the approach and notified air traffic control of the loss of power about 1 minute and 13 seconds later. Subsequently, the pilot contacted the controller again and reported that he was unable to activate the airport's pilot-controlled runway lighting. In the pilot's last radio transmission, he indicated that he was over the airport and was going to "reshoot that approach." The last radar return indicated that the airplane was about 450 ft above ground level at 72 kts groundspeed. The airplane impacted the ground in a steep, vertical nose-down attitude about 1/2 nm from the departure end of the runway. Examination of the wreckage revealed that the landing gear and the flaps were extended and that the right propeller was not feathered. Data from onboard the airplane also indicated that the pilot did not secure the right engine following the loss of power; the left engine continued to produce power until impact. The airplane's fuel system held a total of 203 gallons. Fuel consumption calculations estimated that there should have been about 100 gallons remaining at the time of the accident. The right-wing locker fuel tank remained intact and contained about 14 gallons of fuel. Fuel blight in the grass was observed at the accident site and the blight associated with the right wing likely emanated from the right-wing tip tank. The elevator trim tab was found in the full nose-up position but was most likely pulled into this position when the empennage separated from the aft pressure bulkhead during impact. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although there was adequate fuel on board the airplane, the pilot may have inadvertently moved the right fuel selector to the OFF position or an intermediate position in preparation for landing instead of selecting the right wing fuel tank, or possibly ran the right auxiliary fuel tank dry, which resulted in fuel starvation to the right engine and a total loss of power. The airplane manufacturer's Pilot Operating Handbook (POH) stated that the 20-gallon right- and left-wing locker fuel tanks should be used after 90 minutes of flight. However, 14 gallons of fuel were found in the right-wing locker fuel tank which indicated that the pilot did not adhere to the POH procedures for fuel management. The fuel in the auxiliary fuel tank should be used when the main fuel tank was less than 180 pounds (30 gallons) per tank. As a result of not using all the fuel in the wing locker fuel tanks, the pilot possibly ran the right auxiliary fuel tank empty and was not able to successfully restart the right engine after he repositioned the fuel selector back to the right main fuel tank. Postaccident testing of the airport's pilot-controlled lighting system revealed no anomalies. The airport's published approach procedure listed the airport's common traffic advisory frequency, which activated the pilot-controlled lighting. It is possible that the pilot did not see this note or inadvertently selected an incorrect frequency, which resulted in his inability to activate the runway lighting system. In addition, the published instrument approach procedure for the approach that the pilot was conducting indicated that the runway was not authorized for night landings. It is possible that the pilot did not see this note since he gave no indication that he was going to circle to land on an authorized runway. Given that the airplane's landing gear and flaps were extended, it is likely that the pilot intended to land but elected to go-around when he was unable to activate the runway lights and see the runway environment. However, the pilot failed to reconfigure the airplane for climb by retracting the landing gear and flaps. The pilot had previously failed to secure the inoperative right engine following the loss of power, even though these procedures were designated in the airplane's operating handbook as "immediate action" items that should be committed to memory. It is likely that the airplane was unable to climb in this configuration, and during the attempted go-around, the pilot exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall. Additionally, the pilot had the option to climb to altitude using singleengine procedures and fly to a tower-controlled airport that did not have any landing restrictions, but instead, he decided to attempt a go-around and land at his destination airport.