Crash of a Boeing 737-322 in Mexico City

Date & Time: Nov 26, 2015 at 1828 LT
Type of aircraft:
Operator:
Registration:
XA-UNM
Survivors:
Yes
Schedule:
Cancún – Mexico City
MSN:
24248/1636
YOM:
1988
Flight number:
GMT779
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
139
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12945
Copilot / Total flying hours:
7606
Aircraft flight hours:
64171
Aircraft flight cycles:
39245
Circumstances:
The aircraft departed Cancún on a regular schedule flight to Mexico City, carrying 139 passengers and five crew members. The flight was uneventful. Following an unstabilized approach, the aircraft landed on runway 05L at an excessive speed. After touchdown, severe vibrations occurred when the left main gear collapsed after a course of 1,097 metres. The airplane slid for 980 metres before coming to rest. All 144 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Fracture of the shimmy damper piston and subsequent retraction of the left leg assembly of the landing gear due to vibrations caused during the landing run, which could not be damped due to wear and play existing between the dynamic parts of the links, fittings and apex joint of the shimmy damper.
The following contributing factors were identified:
- Unstabilized approach,
- Inadequate service to shimmy damper and shock strut,
- Landing with a low rate of descent,
- Wear in the Apex joint due to a play between this and the lower torsion link,
- Landing with high ground speed and low descent rate.
Final Report:

Crash of a Boeing 737-3Y0 in Osh

Date & Time: Nov 22, 2015 at 0800 LT
Type of aircraft:
Operator:
Registration:
EX-37005
Survivors:
Yes
Schedule:
Krasnoyarsk – Osh
MSN:
24681/1929
YOM:
1990
Flight number:
AVJ768
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10600
Captain / Total hours on type:
6362.00
Copilot / Total flying hours:
16400
Copilot / Total hours on type:
3731
Aircraft flight hours:
50668
Aircraft flight cycles:
43958
Circumstances:
The crew departed Krasnoyarsk-Yemilianovo Airport on a night flight to Osh, Kyrgyzstan. En route, he was informed that a landing in Osh was impossible to due low visibility caused by foggy conditions. The captain decided to divert to Bishkek-Manas Airport where the aircraft landed safely at 0520LT. As weather conditions seems to improve at destination, the crew left Bishkek bound for Osh some ninety minutes later. On approach to Osh, the vertical visibility was reduced to 130 feet when the aircraft hit violently the runway 12 surface. Upon impact, the left main gear was sheared off, the aircraft slid for several yards, overran, hit obstacles and came to rest in a field located 529 meters past the runway end with its left engine detached and its right engine destroyed. All 154 occupants were evacuated, ten passengers were injured, six of them seriously. The aircraft was damaged beyond repair.
Probable cause:
It was determined that the accident occurred in poor weather conditions with an horizontal visibility reduced to 50 meters and a vertical visibility limited to 130 feet. It was reported that the accident was caused by the combination of the following factors:
- the crew decided to leave Bishkek Airport for Osh without taking into consideration the weather forecast and the possibility of deteriorating weather,
- the competences of the captain for a missed approach procedure in poor weather conditions were limited to a simulator training despite the fact that he was certified for Cat IIIa approaches,
- failure of the crew to comply with the standard operating procedures for a missed approach,
- wrong actions on part of the pilot in command while crossing the runway threshold at a height of 125 feet and about five seconds after the initiation of the TOGA procedure, disrupting the go around trajectory and causing the aircraft to continue the descent,
- lack of reaction of the copilot who did not try to correct the wrong actions of the pilot in command,
- lack of concentration on part of the crew who failed to control the approach speed and failed to recognize the pitch angle that was increasing,
- it is possible that the crew suffered somatogravic illusions caused by fatigue due to a duty time period above 13 hours,
- a non proactive reaction of the crew when the GPWS alarm sounded.
Final Report:

Crash of a Learjet 60 in Zihuatanejo

Date & Time: Nov 16, 2015 at 1622 LT
Type of aircraft:
Operator:
Registration:
XA-UQP
Flight Type:
Survivors:
Yes
Schedule:
Toluca - Zihuatanejo
MSN:
60-202
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7673
Captain / Total hours on type:
1360.00
Copilot / Total flying hours:
9592
Copilot / Total hours on type:
3100
Aircraft flight hours:
3676
Circumstances:
The crew departed Toluca Airport on a positioning flight to Zihuatanejo. Following an uneventful flight, the crew was cleared for a VOR approach to runway 26. Due to the formation of clouds in the vicinity of the airport, ATC changed the clearance and instructed the crew for a VOR/DME approach to runway 08. Following an unstabilized approach, the aircraft landed on a wet runway. After touchdown, the aircraft skidded and veered off runway to the left. In a grassy area, the left main gear impacted a concrete block hosting the electrical system for the runway and was torn off. Then the aircraft slid for few dozen metres before coming to rest. Both pilots evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Runway excursion due to loss of directional control of the aircraft during the landing run on an unstabilized approach.
The following contributing factors were identified:
a) Unstabilized approach,
b) Adverse atmospheric conditions in the "W" area of the airport,
c) Change of designation of runway in use for landing,
d) Lack of adherence to standard operating procedures "SOPS",
e) Lack of adherence to the concepts of "CRM" resource management in the cockpit,
f) Decreased situational awareness on the part of the commander of the aircraft,
g) Flying the approach and descent visually, following an IFR descent within IMC conditions (Instrument Meteorological Conditions),
h) Wet track,
i) Lack of crew coordination,
j) Poor judgement and incorrect decision,
k) Existence of a concrete marker with a level of 10cms protruding above the road surface in the runway safety zone.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Buttles Farm: 4 killed

Date & Time: Nov 14, 2015 at 1134 LT
Registration:
N186CB
Flight Type:
Survivors:
No
Schedule:
Fairoaks – Dunkeswell
MSN:
46-22085
YOM:
1989
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
600
Captain / Total hours on type:
260.00
Circumstances:
The aircraft was approaching Dunkeswell Airfield, Devon after an uneventful flight from Fairoaks, Surrey. The weather at Dunkeswell was overcast, with rain. The pilot held an IMC rating but there is no published instrument approach procedure at Dunkeswell. As the aircraft turned onto the final approach, it commenced a descent on what appeared to be a normal approach path but then climbed rapidly, probably entering cloud. The aircraft then seems to have stalled, turned left and descended to “just below the clouds”, before it climbed steeply again and “disappeared into cloud”. Shortly after, the aircraft was observed descending out of the cloud in a steep nose-down attitude, in what appears to have been a spin, before striking the ground. All four occupants were fatally injured.
Probable cause:
Whilst positioning for an approach to Dunkeswell Airfield, the aircraft suddenly pitched nose-up and entered cloud. This rapid change in attitude would have been disorientating for the pilot, especially in IMC, and, whilst the aircraft was probably still controllable, recovery from this unusual attitude may have been beyond his capabilities. The aircraft appears to have stalled, turned left and descended steeply out of cloud, before climbing rapidly back into cloud. It probably then stalled again and entered a spin from which it did not recover. All four occupants were fatally injured when the aircraft struck the ground. The investigation was unable to determine with certainty the reason for the initial rapid climb. However, it was considered possible that the pilot had initiated the preceding descent by overriding the autopilot. This would have caused the autopilot to trim nose-up, increasing the force against the pilot’s manual input. Such an out-of-trim condition combined with entry into cloud could have contributed to an unintentional and disorientating pitch-up manoeuvre.
Final Report:

Crash of a BAe 125-700A in Akron: 9 killed

Date & Time: Nov 10, 2015 at 1453 LT
Type of aircraft:
Operator:
Registration:
N237WR
Survivors:
No
Site:
Schedule:
Dayton – Akron
MSN:
257072
YOM:
1979
Flight number:
EFT1526
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
6170
Captain / Total hours on type:
1020.00
Copilot / Total flying hours:
4382
Copilot / Total hours on type:
482
Aircraft flight hours:
14948
Aircraft flight cycles:
11075
Circumstances:
The aircraft departed controlled flight while on a non precision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and post crash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR. Contrary to Execuflight’s informal practice of the captain acting as pilot flying on flights carrying revenue passengers, the first officer was the pilot flying, and the captain was the pilot monitoring. While en route, the flight crew began preparing for the approach into AKR. Although company standard operating procedures (SOPs) specified that the pilot flying was to brief the approach, the captain agreed to the first officer’s request that the captain brief the approach. The ensuing approach briefing was unstructured, inconsistent, and incomplete, and the approach checklist was not completed. As a result, the captain and first officer did not have a shared understanding of how the approach was to be conducted. As the airplane neared AKR, the approach controller instructed the flight to reduce speed because it was following a slower airplane on the approach. To reduce speed, the first officer began configuring the airplane for landing, lowering the landing gear and likely extending the flaps to 25° (the airplane was not equipped with a flight data recorder, nor was it required to be). When the flight was about 4 nautical miles from the final approach fix (FAF), the approach controller cleared the flight for the localizer 25 approach and instructed the flight to maintain 3,000 ft mean sea level (msl) until established on the localizer. The airplane was already established on the localizer when the approach clearance was issued and could have descended to the FAF minimum crossing altitude of 2,300 ft msl. However, the first officer did not initiate a descent, the captain failed to notice, and the airplane remained level at 3,000 ft msl. As the first officer continued to slow the airplane from about 150 to 125 knots, the captain made several comments about the decaying speed, which was well below the proper approach speed with 25° flaps of 144 knots. The first officer’s speed reduction placed the airplane in danger of an aerodynamic stall if the speed continued to decay, but the first officer apparently did not realize it. The first officer’s lack of awareness and his difficulty flying the airplane to standards should have prompted the captain to take control of the airplane or call for a missed approach, but he did not do so. Before the airplane reached the FAF, the first officer requested 45° flaps and reduced power, and the airplane began to descend. The first officer’s use of flaps 45° was contrary to Execuflight’s Hawker 700A non precision approach profile, which required the airplane to be flown at flaps 25° until after descending to the minimum descent altitude (MDA) and landing was assured; however, the captain did not question the first officer’s decision to conduct the approach with flaps 45°. The airplane crossed the FAF at an altitude of about 2,700 ft msl, which was 400 ft higher than the published minimum crossing altitude of 2,300 ft msl. Because the airplane was high on the approach, it was out of position to use a normal descent rate of 1,000 feet per minute (fpm) to the MDA. The airplane’s rate of descent quickly increased to 2,000 fpm, likely due to the first officer attempting to salvage the approach by increasing the rate of descent, exacerbated by the increased drag resulting from the improper flaps 45° configuration. The captain instructed the first officer not to descend so rapidly but did not attempt to take control of the airplane even though he was responsible for safety of the flight. As the airplane continued to descend on the approach, the captain did not make the required callouts regarding approaching and reaching the MDA, and the first officer did not arrest the descent at the MDA. When the airplane reached the MDA, which was about 500 ft above the touchdown zone elevation, the point at which Execuflight’s procedures dictated that the approach must be stabilized, the airspeed was 11 knots below the minimum required airspeed of 124 knots, and the airplane was improperly configured with 45° flaps. The captain should have determined that the approach was unstabilized and initiated a missed approach, but he did not do so. About 14 seconds after the airplane descended below the MDA, the captain instructed the first officer to level off. As a result of the increased drag due to the improper flaps 45° configuration and the low airspeed, the airplane entered a stalled condition when the first officer attempted to arrest the descent. About 7 seconds after the captain’s instruction to level off, the cockpit voice recorder (CVR) recorded the first sounds of impact.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s mismanagement of the approach and multiple deviations from company standard operating procedures, which placed the airplane in an unsafe situation and led to an unstabilized approach, a descent below minimum descent altitude without visual contact with the runway environment, and an aerodynamic stall. Contributing to the accident were Execuflight’s casual attitude toward compliance with standards; its inadequate hiring, training, and operational oversight of the flight crew; the company’s lack of a formal safety program; and the Federal Aviation Administration’s insufficient oversight of the company’s training program and flight operations.
Final Report:

Crash of a Boeing 737-4H6 in Lahore

Date & Time: Nov 3, 2015 at 0926 LT
Type of aircraft:
Operator:
Registration:
AP-BJO
Survivors:
Yes
Schedule:
Karachi – Lahore
MSN:
27166/2410
YOM:
1992
Flight number:
NL142
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
114
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19302
Captain / Total hours on type:
4859.00
Copilot / Total flying hours:
2076
Copilot / Total hours on type:
410
Aircraft flight hours:
51585
Aircraft flight cycles:
46547
Circumstances:
On 03rd November 2015, M/s Shaheen Air International Flight NL-142, Boeing 737-400 aircraft Reg # AP-BJO, was on a scheduled passenger flight from Karachi to Lahore. The flight landed on Runway 36L as Runway 36R was not available due to ILS CAT-III up-gradation. After touchdown, both main landing gears broke one after the other. Subsequently, the aircraft departed runway while resting on both engines and stopped 8302 ft from Runway Threshold (RWT), 197ft left of runway centreline. The nose landing gear, however, remained intact. All the passengers were safely evacuated through emergency procedure.
Probable cause:
The accident took place due to:
- Cockpit crew landing the aircraft through unstabilized approach (high ground speed and incorrect flight path).
- Low sink rate of left main landing gear (LMLG) as it touched down and probable presence of (more than the specified limits) play in the linkages of shimmy damper mechanism. This situation led to torsional vibrations / breakage of shimmy damper after touchdown. The resultant torsional excitation experienced by the LMLG due to free pivoting of wheels (along vertical axis) caused collapse of LMLG.
- The RMLG collapsed due to overload as the aircraft moved on unprepared surface.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Kinshasa

Date & Time: Nov 1, 2015
Type of aircraft:
Operator:
Registration:
9Q-CNP
Survivors:
Yes
MSN:
164
YOM:
1965
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Kinshasa-Ndolo Airport, the crew reported technical problems with the undercarriage and was cleared to divert to Kinshasa-N'Djili Airport. A belly landing was completed on runway 24 and the aircraft slid for few dozen metres then veered off runway to the right and came to rest in a grassy area. All 26 occupants evacuated safely and the aircraft was damaged beyond repair. It is believed that the left main gear was torn off upon takeoff from Kinshasa-Ndolo Airport for unknown reasons.

Crash of a Piper PA-31-350 Navajo Chieftain in Weston

Date & Time: Oct 26, 2015 at 1233 LT
Operator:
Registration:
N55GK
Survivors:
Yes
Schedule:
Jacksonville – Fort Lauderdale
MSN:
31-7852013
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
105.00
Aircraft flight hours:
6003
Circumstances:
The airline transport pilot of the multiengine airplane had fueled the main (inboard) fuel tanks to capacity before the cross-county flight. As the flight approached the destination airport, an air traffic controller instructed the pilot to turn right for a visual approach, and the pilot acknowledged. Subsequently, the pilot reported that he might have to land on a highway. The airplane impacted a marsh area about 15 miles from the destination airport. Review of data downloaded from an onboard engine monitor revealed that the right engine momentarily lost and regained power before experiencing a total loss of power. Examination of the wreckage revealed that the left propeller was feathered and that the right propeller was in the normal operating range. Sufficient fuel to complete the flight was drained from the left wing fuel tanks. Although the right wing fuel tanks were compromised during the impact, sufficient fuel was likely present in the right main fuel tanks to complete the flight before impact because both the left and right main fuel tanks were fueled to capacity concurrently before the flight, but it likely was in a low fuel state due to fuel used during the flight. The right wing main fuel tank was not equipped with a flapper valve, which should have been located on the baffle nearest the wing root where the fuel pickup was located. The flapper valve is used to trap fuel near the fuel pickup and prevent it from flowing outboard away from the pickup. The maintenance records did not indicate that the right main fuel tank bladder had been replaced; however, the manufacture year printed on the bladder was about 20 years before the accident and 16 years after the manufacture of the airplane, indicating that the bladder had been replaced at some point. When the right main fuel tank bladder was replaced, the flapper valve would have been removed. Based on the evidence, it is likely that maintenance personnel failed to reinstall the flapper valve after installing the new fuel bladder. This missing valve would not affect operation of the fuel system unless the right main fuel tank was in a low fuel state, when fuel could flow outboard away from the fuel pickup (such as in a right turn, which the pilot was making when the engine lost power), and result in fuel starvation to the engine.Toxicology testing of the pilot revealed that his blood alcohol level during the flight was likely between 0.077 gm/dl and 0.177 gm/dl, which is above the level generally considered impairing. Therefore, it is likely that, during the right turn, the fuel in the right main fuel tank moved outboard, which resulted in fuel starvation to the right engine. When the right engine lost power, the pilot should have secured the right engine by feathering the propeller to reduce drag and increase single-engine performance; however, given the position of the propellers at the accident site, the pilot likely incorrectly feathered the operating (left) engine, which rendered the airplane incapable of maintaining altitude. It is very likely that the pilot's impairment due to his ingestion of alcohol led to his errors and contributed to the accident.
Probable cause:
The pilot's feathering of the incorrect propeller following a total loss of right engine power due to fuel starvation, which resulted from maintenance personnel's failure to reinstall the flapper valve in the right main fuel tank. Contributing to the accident was the pilot's impairment due to alcohol consumption.
Final Report:

Crash of a Boeing 737-4L7 in Johannesburg

Date & Time: Oct 26, 2015 at 1206 LT
Type of aircraft:
Operator:
Registration:
ZS-OAA
Survivors:
Yes
Schedule:
Port Elizabeth - Johannesburg
MSN:
26960/2483
YOM:
1993
Flight number:
BA6234
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
2899.00
Copilot / Total flying hours:
5817
Copilot / Total hours on type:
480
Aircraft flight hours:
57543
Circumstances:
The aircraft Boeing 737-400, operated by Comair, flight number BA6234, was on a scheduled domestic flight operated under the provisions of Part 121 of the Civil Aviation Regulations (CARs). The aircraft was on the third leg for the day, after it had performed two uneventful legs. According to their recorded flight plan, the first leg departed from King Shaka International Airport (FALE) to O.R. Tambo International Airport (FAOR), the second leg was from FAOR to Port Elizabeth International Airport (FAPE) on the same day, during which the Captain was flying. During this third leg, the aircraft departed from FAPE at 0820Z on an instrument flight plan rule for FAOR. On board were six (6) crew members, ninety four (94) passengers and two (2) live animals. The departure from FAPE was uneventful, whereby the first officer (FO) was the flying pilot (FP) for this leg. During the approach to FAOR, the aircraft was cleared for landing on runway 03R. The accident occurred at approximately 1 km past the threshold. The crew stated that a few seconds after a successful touchdown, they felt the aircraft vibrating, during which they applied brakes and deployed the reverse thrust. The vibration was followed by the aircraft rolling slightly low to the left. It later came to a full stop slightly left of the runway centre line, resting on its right main landing gear and the number one engine, with the nose landing gear in the air. The crash alarm was activated by the FAOR Air Traffic Controller (ATC). The Airport Rescue and Fire Fighting (ARFF) personnel responded swiftly to the scene of the accident. The accident site was then secured with all relevant procedures put in place. The aircraft sustained substantial damage as the number one engine scraped along the runway surface when the landing gear detached from the fuselage. ARFF personnel had to prevent an engine fire in which they saw smoke as a result of runway contact. The occupants were allowed to disembark from the aircraft via the left aft door due to the attitude in which the aircraft came to rest. The accident occurred during daylight meteorological conditions on Runway 03R at O.R. Tambo International Airport (FAOR) located at GPS reading as: S 26°08’01.30” E 028°14’32.34” and the field elevation 5558 ft.
Probable cause:
Unstable approach whereby the aircraft was flared too high with high forward speed resulting with a low sink rate in which during touch down the left landing gear
experienced excessive vibration and failed due to shimmy events.
The following findings were identified:
- According to the FDR recordings, the aircraft flare was initiated earlier at 65ft than at 20ft as recommended by aircraft manufacture, which contributed to the low sink rate.
- The shimmy damper failed the post-accident lab-test and fluid was found in the thermal relief valve, which could have contributed to the shimmy damper failure.
- According to the lab results, significant wear was found on the upper torsion link bushing and flange, which could have contributed to undamped vibration
continuation.
- The aircraft had a tailwind component during landing, which could have prolonged the landing distance.
Final Report:

Crash of a Boeing 737-3K2 in Cuzco

Date & Time: Oct 23, 2015 at 1115 LT
Type of aircraft:
Operator:
Registration:
OB-2040-P
Survivors:
Yes
Schedule:
Lima - Cuzco
MSN:
24329/1858
YOM:
1990
Flight number:
P9216
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
133
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6352
Captain / Total hours on type:
1971.00
Copilot / Total flying hours:
1455
Copilot / Total hours on type:
1219
Aircraft flight hours:
74018
Aircraft flight cycles:
42389
Circumstances:
Following an uneventful flight from Lima, the crew started the descent to Cuzco-Alejandro Velasco Astete Airport Runway 28. On approach, the aircraft was configured for landing and flaps were deployed to 15°. Following a smooth landing, the crew started the braking procedure when, eight seconds after touchdown, he noticed vibrations coming from the left main gear. At a speed of 100 knots, the right main gear collapsed. The aircraft rolled for few hundred metres then came to a halt on the runway. All 139 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Unstable approach and inadequate landing technique for high altitude fields, which resulted in increased landing speed, the start of the flare manoeuvre at higher altitude, and low descent speed, which made the OB-2040-P aircraft make soft contact with the runway, causing inefficiency in operation of the shimmy damper, which did not prevent uncontrolled oscillation of the shock absorbers.
Contributing factors:
- Lack of instruction and training in simulators that include techniques and maneuvers of landing at high altitude fields, with emphasis on speed control at landing.
- Lack of a performance analysis process, through the use of flight recorders or other installed data recording equipment and flight parameters, by the operating company, to enable supervision, control and corrective measures in the operational use of its aircraft.
Final Report: