Crash of a Boeing 737-85C in Manila

Date & Time: Aug 16, 2018 at 2355 LT
Type of aircraft:
Operator:
Registration:
B-5498
Survivors:
Yes
Schedule:
Xiamen – Manila
MSN:
37574/3160
YOM:
2010
Flight number:
MF8667
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 16, 2018, about 1555UTC/2355H local time, a Boeing 737-800 type of aircraft with Registry No. B-5498 operating as flight CXA 8667 sustained substantial damage following a runway excursion after second approach while landing on Runway 24 of Ninoy Aquino International Airport (NAIA), Manila, Philippines. The flight was a scheduled commercial passenger from Xiamen, China and operated by Xiamen Airlines. The one hundred fifty-seven (157) passengers and two (2) pilots together with the five (5) cabin crew and one air security officer did not sustain any injuries while the aircraft was substantially damaged. An instrument flight rules flight plan was filed. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident. During the first approach, the Captain who was the pilot flying aborted the landing at 30 feet Radio Altitude (RA) due to insufficient visual reference. A second approach was considered and carried out after briefing the First Officer (FO) of the possibility of another aborted landing should the flight encounter similar conditions. The briefing included a diversion to their planned alternate airfield. The flight was “stabilized” on the second approach with flaps set at 30 degrees landing position, all landing gears extended and speed brake lever appropriately set in the ARM position. On passing 1,002 feet Radio Altitude (RA), the autopilot was disengaged; followed by the disengagement of the auto-throttle, three (3) seconds later. The ILS localizer lateral path and Glide slope vertical path were accurately tracked and no deviations were recorded. The “reference” landing speed for flaps 30 for the expected aircraft gross weight at the time of landing was 145 knots and a target speed of 150 knots was set on the Mode Control Panel (MCP). The vertical descent rate recorded during the approach was commensurate with the recommended descent rate for the profile angle and ground speed; and was maintained throughout the approach passing through the Decision Altitude (DA) of 375 feet down to 50 feet radio altitude (RA). As the aircraft passed over the threshold, the localizer deviation was established around zero dot but indicated the airplane began to drift to the left of the centerline followed by the First Officer (FO) making a call out of “Go-Around” but was answered by the Captain “No”. The throttle levers for both engines were started to be reduced to idle position at 30 feet RA and became fully idle while passing five (5) feet RA. At this point, the aircraft was in de-crab position prior to flare. At 13 feet RA, the aircraft was rolling left and continuously drifting left of the runway center line. At 10 feet RA another call for go-around was made by the FO but was again answered by the Captain with “No” and “It’s Okay”. At this point, computed airspeed was approximately 6 knots above MCP selected speed and RA was approaching zero feet. Just prior to touchdown, computed airspeed decreased by 4 knots and the airplane touched down at 151 knots (VREF+6). The wind was recorded at 274.7 degrees at 8.5 knots. Data from the aircraft’s flight data recorder showed that the aircraft touched down almost on both main gears, to the left of the runway centerline, about 741 meters from the threshold of runway 24. Deployment of the speed brakes was recorded and auto brakes engagement was also recorded. The auto brakes subsequently disengaged but the cause was undetermined. Upon touchdown, the aircraft continued on its left-wards trajectory while the aircraft heading was held almost constant at 241 degrees. After the aircraft departed the left edge of the runway, all landing gears collided with several concrete electric junction boxes that were erected parallel outside the confines of the runway pavement. The aircraft was travelling at about 147 knots as it exited the paved surface of the runway and came to rest at approximately 1,500 meters from the threshold of Runway 24, with a geographical position of 14°30’23.7” N; 121°0’59.1” E and a heading of 120 degrees. Throughout the above sequence of events from touchdown until the aircraft came to a full stop, the CVR recorded 2 more calls of “GO-AROUND” made by the FO. Throughout the landing sequence, the thrust reversers for both engines were not deployed. Throttle Lever Position (TLP) were recorded and there was no evidence of reverse thrust being selected or deployment of reversers. After the aircraft came to a complete stop, the pilots carried out all memory items and the refence items in the evacuation non-normal checklist, which includes extending the flaps to a 40 degrees position. The aircraft suffered total loss of communication and a failure in passenger address system possibly due to the damage caused by the nose gear collapsing rearwards and damaging the equipment in the E/E compartment or the E-buss wires connecting the Very High Frequency (VHF) 1 radio directly to the battery was broken. The Captain then directed the FO to go out of the cockpit to announce the emergency evacuation. The cabin crew started the evacuation of the passengers utilizing the emergency slides of the left and right forward doors. There were no reported injuries sustained by the passengers, cabin crew, flight crew or the security officer.
Probable cause:
Primary causal factors:
a. The decision of the Captain to continue the landing on un-stabilized approach and insufficient visual reference.
- The Captain failed to maintain a stabilized landing approach moments before touchdown, the aircraft was rolling left and continuously drifting left of the runway centerline.
- The Captain failed to identify correctly the aircraft position and status due to insufficient visual reference caused by precipitation.
b. The Captain failed to apply sound CRM practices.
- The Captain did not heed to the First Officer call for a Go-Around.
Contributory factors:
a. Failure to apply appropriate TEM strategies. Failure of the Flight Crew to discuss and apply appropriate Threat and Error Management (TEM) strategies for the following:
- Inclement weather.
- Cross wind conditions during approach to land.
- Possibility of low-level wind shear.
- NOTAM information on unserviceable runway lights.
b. Inadequate Company Policy on Go-Around:
- Company’s Standard Operation Procedures were less than adequate in terms of providing guidance to the flight crew for call out of "Go-Around" during landing phase of the flight.
c. Runway strip inconsistent with CAAP MOS for Aerodrome and ICAO Annex 14:
- The uneven surface and concrete obstacles contributed to the damage sustained by the aircraft.
Final Report:

Crash of a Pacific Aerospace PAC 750XL near Oksibil: 8 killed

Date & Time: Aug 11, 2018 at 1420 LT
Operator:
Registration:
PK-HVQ
Survivors:
Yes
Site:
Schedule:
Tanah Merah – Oksibil
MSN:
144
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
13665
Captain / Total hours on type:
1468.00
Aircraft flight hours:
4574
Aircraft flight cycles:
5227
Circumstances:
On 11 August 2018, a PAC 750XL aircraft registered PK-HVQ was being operated by PT. Marta Buana Abadi (Dimonim Air) on unscheduled passenger flight from Tanah Merah to Oksibil. At the day of the occurrence the meteorological condition at Oksibil was below the requirement of Visual Flight Rule (VFR) weather minima and did not improve. Being aware that some flights had performed flight to Tanah Merah to Oksibil and returned, the pilot decided to fly to Oksibil. At 1342 LT, on daylight condition the PK-HVQ aircraft departed from Tanah Merah to Oksibil, on board the aircraft were one pilot, one observer pilot and 7 passengers. According to the passenger and cargo manifest, the total weight of passenger and the baggage were 473 kg. Prior to the departure, there was no record or report of aircraft system malfunction. At 1411 LT, the PK-HVQ pilot made initial contact to Oksibil Tower controller and reported that the aircraft was maintaining altitude of 7,000 feet over and the estimate time arrival at Oksibil would be 0520 UTC (1420 LT). The Oksibil Tower controller advised the pilot of the latest meteorological condition that the visibility was 1 up to 2 km and most of the area were covered by cloud. At 1416 LT, the pilot reported that the aircraft position was over Oksibil Aiport and the Oksibil Tower controller instructed the pilot to continue the flight to the final runway 11 and to report when the runway had in sight. The Oksibil Tower controller and pilots of other aircraft called the pilot but no reply. On the following day, the aircraft was found on a ridge of mountain about 3.8 Nm north west of Oksibil on bearing 331° with elevation about 6,800 feet. Eight occupants were fatally injured and one occupant was seriously injured.
Probable cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly most likely had made the pilot did not have a clear visual to the surrounding area.
- Considering that the Pilot in Command (PIC) had lack knowledge of the terrain surrounding the Oksibil area, and the absence of voice alert from the TAWS when the aircraft flying close to terrain, resulted in the PIC did not have adequate awareness to the surrounding terrain while flying into clouds and continued to fly below the terrain height until the aircraft impacted the terrain.
Final Report:

Crash of a Dassault Falcon 20D in San Luis Potosí

Date & Time: Aug 7, 2018 at 0110 LT
Type of aircraft:
Operator:
Registration:
N961AA
Flight Type:
Survivors:
Yes
Schedule:
Santiago de Querétaro - Laredo
MSN:
205
YOM:
1969
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Santiago de Querétaro Airport on a night cargo flight to Laredo, Texas, carrying two pilots and a load consisting of automotive parts. En route, the crew encountered engine problems and was clearted to divert to San Luis Potosí-Ponciano Arriaga Airport for an emergency landing. On approach, the crew realized he could not make it and decided to attempt an forced landing. The airplane struck the ground, lost its undercarriage and came to rest in an agricultural area located in Peñasco, about 6 km northeast of runway 14 threshold. The left wing was bent and partially torn off. Both crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Cessna 414 Chancellor in Santa Ana: 5 killed

Date & Time: Aug 5, 2018 at 1229 LT
Type of aircraft:
Registration:
N727RP
Flight Type:
Survivors:
No
Site:
Schedule:
Concord – Santa Ana
MSN:
414-0385
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
980
Captain / Total hours on type:
120.00
Aircraft flight hours:
3963
Circumstances:
The pilot and four passengers were nearing the completion of a cross-county business flight. While maneuvering in the traffic pattern at the destination airport, the controller asked the pilot if he could accept a shorter runway. The pilot said he could not, so he was instructed to enter a holding pattern for sequencing; less than a minute later, the pilot said he could accept the shorter runway. He was instructed to conduct a left 270° turn to enter the traffic pattern. The pilot initiated a left bank turn and then several seconds later the bank increased, and the airplane subsequently entered a steep nose-down descent. The airplane impacted a shopping center parking lot about 1.6 miles from the destination airport. A review of the airplane's flight data revealed that, shortly after entering the left turn, and as the airplane’s bank increased, its airspeed decreased to about 59 knots, which was well below the manufacturer’s published stall speed in any configuration. Postaccident examination of the airframe and engines revealed no anomalies that would have precluded normal operation. It is likely that the pilot failed to maintain airspeed during the turn, which resulted in an exceedance of the aircraft's critical angle of attack and an aerodynamic stall.
Probable cause:
The pilot’s failure to maintain adequate airspeed while maneuvering in the traffic pattern which resulted in an aerodynamic stall and subsequent spin at a low altitude, which the pilot was unable to recover from.
Final Report:

Crash of a Piper PA-60-602P Aerostar (Ted Smith 600) in Greenville: 3 killed

Date & Time: Jul 30, 2018 at 1044 LT
Operator:
Registration:
C-GRRS
Flight Type:
Survivors:
No
Schedule:
Pembroke – Charlottetown
MSN:
60-8265-026
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
590
Captain / Total hours on type:
136.00
Aircraft flight hours:
4856
Circumstances:
The private pilot of the multiengine airplane was in cruise flight at 23,000 ft mean sea level (msl) in day visual meteorological conditions when he reported to air traffic control that the airplane was losing altitude due to a loss of engine power. The controller provided vectors to a nearby airport; about 7 minutes later, the pilot reported the airport in sight and stated that he would enter a downwind leg for runway 14. By this time, the airplane had descended to about 3,200 ft above ground level. Radar data indicated that the airplane proceeded toward the runway but that it was about 400 ft above ground level on short final. The airplane flew directly over the airport at a low altitude before entering a left turn to a close downwind for runway 21. Witnesses stated that the airplane's propellers were turning, but they could not estimate engine power. When the airplane reached the approach end of runway 21, it entered a steep left turn and was flying slowly before the left wing suddenly "stalled" and the airplane pitched nose-down toward the ground. Postaccident examination of the airplane and engines revealed no mechanical deficiencies that would have precluded normal operation at the time of impact. Examination of both propeller systems indicated power symmetry at the time of impact, with damage to both assemblies consistent with low or idle engine power. The onboard engine monitor recorded battery voltage, engine exhaust gas temperature, and cylinder head temperature for both engines. A review of the recorded data revealed that about 14 minutes before the accident, there was a jump followed by a decrease in exhaust gas temperature (EGT) and cylinder head temperature (CHT) for both engines. The temperatures decreased for about 9 minutes, during which time the right engine EGT data spiked twice. Both engines' EGT and CHT values then returned to normal, consistent with both engines producing power, for the remaining 5 minutes of data. It is possible that a fuel interruption may have caused the momentary increase in both engines' EGT and CHT values and prompted the pilot to report the engine power loss; however, the engine monitor did not record fuel pressure or fuel flow, and examination of the airplane's fuel system and engines did not reveal any mechanical anomalies. Therefore, the reason for the reported loss of engine power could not be determined. It is likely that the pilot's initial approach for landing was too high, and he attempted to circle over the airport to lose altitude. While doing so, he exceeded the airplane's critical angle of attack while in a left turn and the airplane entered an aerodynamic stall at an altitude too low for recovery.
Probable cause:
The pilot's exceedance of the airplane's critical angle of attack while maneuvering to land, which resulted in an aerodynamic stall.
Final Report:

Crash of a Beechcraft C90GTi King Air in Campo de Marte: 1 killed

Date & Time: Jul 29, 2018 at 1810 LT
Type of aircraft:
Operator:
Registration:
PP-SZN
Survivors:
Yes
Schedule:
Videira – Campo de Marte
MSN:
LJ-1910
YOM:
2008
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While approaching Campo de Marte Airport by night following an uneventful flight from Videira, the crew encountered technical problems with the landing gear and was cleared to complete two low passes over the runway to confirm visually the problem. While performing a third approach, the twin engine airplane rolled to the left then overturned and crashed inverted about 100 metres to the left of runway 30, bursting into flames. Six occupants were injured and one pilot was killed.

Crash of a Curtiss C-46F-1-CU Commando in Manley Hot Springs

Date & Time: Jul 16, 2018 at 0925 LT
Type of aircraft:
Operator:
Registration:
N1822M
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks – Kenai
MSN:
22521
YOM:
1945
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
300
Copilot / Total hours on type:
135
Aircraft flight hours:
37049
Circumstances:
The pilot reported that, following a precautionary shutdown of the No. 2 engine, he diverted to an alternate airport that was closer than the original destination. During the landing in tailwind conditions, the airplane touched down "a little fast." The pilot added that, as the brakes faded from continuous use, the airplane was unable to stop, and it overran the end of the runway, which resulted in substantial damage to the fuselage. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause:
The pilot's failure to attain the proper touchdown speed and his decision to land with a tailwind without ensuring that there was adequate runway length for the touchdown.
Final Report:

Crash of a Douglas DC-3C in San Felipe

Date & Time: Jul 11, 2018 at 1220 LT
Type of aircraft:
Operator:
Registration:
HK-3293
Flight Type:
Survivors:
Yes
Schedule:
Inírida – San Felipe
MSN:
9186
YOM:
1943
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Captain / Total hours on type:
16000.00
Copilot / Total flying hours:
7784
Copilot / Total hours on type:
1715
Aircraft flight hours:
29170
Circumstances:
The aircraft departed Inírida on a humanitarian flight to San Felipe, carrying nine passengers, three crew members and various goods and equipment dedicated to the victims of the recent floods. Following an uneventful flight, the crew landed on runway 18. After touchdown, the aircraft deviated to the left. It pivoted to the left, lost its left main gear and the left propeller and came to a halt on the runway edge. All 12 occupants were rescued, among them one passenger was slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of a lateral runway excursion as a result of a loss of control on the ground caused by the loss of air pressure in the left main gear tire, as a result of the penetration of a FOD (metallic object) into the tire during the landing run. Poor risk management by the San Felipe Aerodrome operator (SKFP) and a lack of a runway FOD control program (SKFP) by the operator of the aerodrome was considered as contributing factors.
Final Report:

Crash of a Convair CV-340 in Pretoria: 1 killed

Date & Time: Jul 10, 2018 at 1639 LT
Type of aircraft:
Operator:
Registration:
ZS-BRV
Flight Type:
Survivors:
Yes
Schedule:
Pretoria - Sun City
MSN:
215
YOM:
1954
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
18240
Captain / Total hours on type:
63.00
Copilot / Total flying hours:
19616
Aircraft flight hours:
18115
Circumstances:
On Tuesday 10 July 2018, at approximately 1439Z, two crew members and 17 passengers took off on a ZS-BRV aircraft for a scenic flight from Wonderboom Aerodrome (FAWB) destined for Pilanesberg Aerodrome (FAPN) when the accident occurred. During take-off, the left engine caught fire, however, the crew continued with the flight. They declared an emergency by broadcasting ‘MAYDAY’ and requesting to return to the departure aerodrome. The crew turned to the right with the intention of returning to the aerodrome. However, the left engine fire intensified, causing severe damage to the left wing rear spar and left aileron system, resulting in the aircraft losing height and the crew losing control of the aircraft and colliding with power lines, prior to crashing into a factory building. The footage taken by one of the passengers using their cellphone showed flames coming from the front top side of the left engine cowling and exhaust area after take-off. The air traffic control (ATC) on duty at the time of the accident confirmed that the left engine had caught fire during take-off and that the crew had requested clearance to return to the aerodrome. The ATC then activated the crash alarm and the aircraft was prioritized for landing. During the accident sequence that followed, one passenger (engineer) occupying the jump seat in the cockpit was fatally injured and 18 others sustained injuries. The investigation revealed that during take-off, the left engine had caught fire and the crew had continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew had then declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. Owned by Rovos Air (part of the South African Rovos Rail Group), the aircraft was donated to the Dutch Museum Aviodrome based in Lelystad and has to be transferred to Europe with a delivery date on 23 July 2018. For this occasion, the aircraft was repaint with full Martin's Air Charter colorscheme. Part of the convoy program to Europe, the airplane was subject to several test flights, carrying engineers, technicians, pilots and also members of the Aviodrome Museum.
Probable cause:
During take-off, the left engine caught fire and the crew continued with the flight without securing the left engine as prescribed in the aircraft flight manual (AFM). The crew declared an emergency and attempted to return to the aerodrome, however, they lost control of the aircraft and collided with power lines prior to crashing into a factory building. The following contributing factors were reported:
- Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft,
- Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident,
- Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident,
- The crew not aborting take-off at 50 knots prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50 knots and that should have resulted in an aborted take-off,
- Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire,
- Lack of recency training for both the PF and PM, as well as the LAME,
- Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.
Final Report:

Crash of a Beechcraft C90A King Air in Mumbai: 5 killed

Date & Time: Jun 28, 2018 at 1315 LT
Type of aircraft:
Operator:
Registration:
VT-UPZ
Flight Type:
Survivors:
No
Site:
Schedule:
Juhu - Juhu
MSN:
LJ-1400
YOM:
1995
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Following a technical maintenance, a test flight was scheduled with two engineers and two pilots. The twin engine airplane departed Mumbai-Juhu Airport and the crew completed several manoeuvres over the city before returning. On approach in heavy rain falls, the aircraft went out of control and crashed at the bottom of a building under construction located in the Ghatkopar West district, some 3 km east from Mumbai Intl Airport, bursting into flames. The aircraft was destroyed by impact forces and a post crash fire and all four occupants were killed as well as one people on the ground.