Crash of a Boeing 737-4Y0 in Kabul

Date & Time: May 8, 2014 at 1704 LT
Type of aircraft:
Operator:
Registration:
YA-PIB
Survivors:
Yes
Schedule:
New Delhi – Kaboul
MSN:
26077/2425
YOM:
1993
Flight number:
FG312
Location:
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
122
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from New Delhi-Indira Gandhi Airport, the crew was cleared for an ILS approach to Kabul Airport Runway 29. On short final, the aircraft entered an area of heavy rain falls. The crew continued the approach and the aircraft landed after the touchdown zone. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage, collided with the ILS antenna and slid for 285 metres before coming to rest. All 132 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew completed the landing too far down the runway, reducing the landing distance available. The following contributing factors were identified:
- The crew failed to follow SOP's,
- Poor crew recurrent training,
- The thrust reverse systems were activated too late after landing.

Crash of a Boeing 737-476SF in East Midlands

Date & Time: Apr 29, 2014 at 0228 LT
Type of aircraft:
Operator:
Registration:
EI-STD
Flight Type:
Survivors:
Yes
Schedule:
Paris-Roissy-Charles de Gaulle – East Midlands
MSN:
24433/1881
YOM:
1990
Flight number:
ABR1748
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4279
Captain / Total hours on type:
377.00
Copilot / Total flying hours:
3900
Circumstances:
The aircraft was scheduled to operate three commercial air transport (cargo) sectors: from Athens to Bergamo, then to Paris Charles de Gaulle, and finally East Midlands. The aircraft’s flap load relief system was inoperative, which meant that the maximum flap position to be used in flight was 30, rather than 40º. This defect had been deferred in the aircraft’s technical log and it had no effect on the landing of the aircraft. Otherwise, the aircraft was fully serviceable. The co-pilot completed the pre-flight external inspection of the aircraft in good light, and found nothing amiss. The departure from Athens was uneventful, but a combination of factors affecting Bergamo (including poor weather, absence of precision approach aids, and work in progress affecting the available landing distance) led the crew to decide to route directly to Paris, where a normal landing was carried out. The aircraft departed Paris for East Midlands at 0040 hrs, loaded with 10 tonnes of freight, 8 tonnes of fuel (the minimum required was 5.6 tonnes), and with the co-pilot as Pilot Flying. Once established in the cruise, the flight crew obtained the latest ATIS information from East Midlands, which stated that Runway 27 was in use, although there was a slight tailwind, and Low Visibility Procedures (LVPs) were in force. They planned to exchange control at about FL100 in the descent, for the commander to carry out a Category III autoland. However, as they neared their destination, the weather improved, LVPs were cancelled, and the flight crew re-briefed for an autopilot approach, followed by a manual landing, to be carried out by the co-pilot. The landing was to be with Flap 30, Autobrake 2, and idle reverse thrust. The final ATIS transmission which the flight crew noted before landing stated that the wind was 130/05 kt, visibility was 3,000 metres in mist, and the cloud was broken at 600 ft aal. The commander of EI-STD established radio contact with the tower controller, and the aircraft was cleared to land; the surface wind was transmitted as 090/05 kt. The touchdown was unremarkable, and the autobrake functioned normally, while the co-pilot applied idle reverse thrust on the engines. As the aircraft’s speed reduced through approximately 60 kt, the co-pilot handed control to the commander, who then made a brake pedal application to disengage the autobrake system. However, the system remained engaged, so he made a second, more positive, brake application. The aircraft “shuddered” and rolled slightly left-wing-low as the lower part of the left main landing gear detached. The commander used the steering tiller to try to keep the aircraft tracking straight along the runway centreline, but it came to a halt slightly off the centreline, resting on its right main landing gear, the remains of the left main landing gear leg, and the left engine lower cowl. The co-pilot saw some smoke drift past the aircraft as it came to a halt. The co-pilot made a transmission to the tower controller, reporting that the aircraft was in difficulties, after which the co-pilot of another aircraft (which was taxiing from its parking position along the parallel taxiway) made a transmission referring to smoke from the 737’s landing gear. The commander of EI-STD had reached the conclusion that one of the main landing gear legs had failed, but as a result of the other pilot’s transmission, he was also concerned that the aircraft might be on fire. The commander immediately moved both engine start levers to the cut-off positions, shutting down the engines. Three RFFS vehicles had by now arrived at the adjacent taxiway intersection, and their presence there prompted the commander to consider that the aircraft was not on fire (he believed that if it were, the vehicles would have adopted positions closer by and begun to apply fire-fighting media). The RFFS vehicles then moved closer to the aircraft and fire-fighters placed a ladder against door L1, which the co-pilot had opened. Having spoken to fire-fighters while standing in the entrance vestibule, the commander returned to the flight deck and switched off the battery. The flight crew were assisted from the aircraft and fire-fighters applied foam around the landing gear and engine to make the area safe. The commander had taken the Notoc2 with him from the aircraft, and informed fire-fighters of the dangerous goods on board the aircraft.
Probable cause:
The damage to the flap system, fuselage, and MLG equipment was attributable to the detachment of the left MLG axle, wheel and brake assembly. The damage to the MLG outer cylinder, engine and nacelle was as result of the aircraft settling and sliding along the runway. The left MLG axle assembly detached from the inner cylinder due to the momentary increase in bending load during the transition from auto to manual braking. The failure was as a result of stress corrosion cracking and fatigue weakening the high strength steel substrate at a point approximately 75 mm above the axle. It is likely that some degree of heat damage was sustained by the inner cylinder during the overhaul process, as indicated by the presence of chicken wire cracking within the chrome plating over the majority of its surface. However, this was not severe enough to have damaged the steel substrate and therefore may have been coincidental. Although the risk of heat damage occurring during complex landing gear plating and refinishing processes is well understood and therefore mitigated by the manufacturers and overhaul agencies, damage during the most recent refinishing process cannot be discounted. The origin of the failure was an area of intense, but very localized heating, which damaged the chrome protection and changed the metallurgy; ie the formation of martensite within the steel substrate. This resulted in a surface corrosion pit, which, along with the metallurgical change, led to stress corrosion cracking, fatigue propagation and the eventual failure of the inner cylinder under normal loading.
Final Report:

Crash of a Piper PA-31-310 Navajo in Deán Funes

Date & Time: Apr 27, 2014 at 1915 LT
Type of aircraft:
Operator:
Registration:
LV-JGN
Flight Type:
Survivors:
Yes
Schedule:
Termas de Río Hondo – Río Cuarto
MSN:
31-213
YOM:
1968
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
462
Captain / Total hours on type:
8.00
Aircraft flight hours:
5245
Circumstances:
The twin engine aircraft departed Termas de Río Hondo Airport on a flight to Río Cuarto, carrying six passengers and one pilot who took part to a motorcycle GP in Termas de Río Hondo. About 45 minutes into the flight, while cruising at an altitude of 6,500 feet, the left engine failed. The pilot contacted ATC and was cleared to divert to Deán Funes Airfield. On approach, he realized he could not make it and attempted an emergency landing on the National Road 60 at km 835. After touchdown, the aircraft veered off the street, lost its nose gear and came to rest in bushes. One passenger and the pilot were injured while five other occupants escaped unhurt. The aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Failure of the left engine in cruising flight due to the failure of the fuel injection system connected to the cylinder n°3,
- Inadequate maintenance of the aircraft and engine and non application of the bulletins related to the maintenance of the injection system,
- Impossibility for the pilot to increase engine power due to the high temperature of the cylinder,
- The aircraft's performances were degraded,
- Late decision of the pilot to attempt an emergency landing at dusk,
- Insufficient information regarding the procedure to feather the propeller.
Final Report:

Crash of a Fokker 50 in Guriceel

Date & Time: Apr 20, 2014
Type of aircraft:
Operator:
Registration:
5Y-VVJ
Flight Type:
Survivors:
Yes
Schedule:
Nairobi – Guriceel
MSN:
20133
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Nairobi-Wilson Airport on a cargo flight to Guriceel, carrying two pilots and a load of six tons of khat. After landing, the crew encountered difficulties to stop the airplane within the remaining distance. The aircraft overran and came to rest with its left wing partially torn off. Both pilots evacuated safely and the aircraft was damaged beyond repair.

Crash of a BAe 125-700A in Saltillo: 8 killed

Date & Time: Apr 19, 2014 at 1946 LT
Type of aircraft:
Registration:
XA-UKR
Survivors:
No
Site:
Schedule:
Cozumel - Saltillo
MSN:
257191
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
12984
Captain / Total hours on type:
4470.00
Copilot / Total flying hours:
620
Copilot / Total hours on type:
67
Aircraft flight hours:
6166
Aircraft flight cycles:
4699
Circumstances:
Following an uneventful flight from Cozumel, the crew initiated an ILS/DME2 approach to Saltillo-Plan de Guadalupe Airport Runway 17. On final, the crew encountered poor visibility due to foggy conditions. Despite he was unable to establish a visual contact with the runway, the crew continued the approach and descended below the MDA when the aircraft collided with power cables and crashed on a building located in an industrial park, 1,448 metres short of runway. The aircraft was destroyed by impact forces and a post crash fire and all eight occupants were killed. The building was also destroyed by fire. At the time of the accident, the horizontal visibility was estimated to be 800 metres with a vertical visibility of 200 feet.
Probable cause:
The accident was the consequence of the decision of the crew to continue the approach below MDA in IMC conditions until the aircraft collided with power cables and impacted ground. The following contributing factors were identified:
- The approach was unstable,
- The decision of the crew to continue the approach below MDA without visual contact with the runway,
- Poor safety culture by the operator,
- The crew failed to comply with procedures related to an ILS/DME2 approach to runway 17,
- Lack of crew resources management,
- The crew failed to respond to the GPWS alarm,
- The crew did not monitor the altitude during the final approach,
- Poor weather conditions with a visibility below minimums,
- Inadequate maintenance controls,
- The crew failed to follow the SOP's.
Final Report:

Crash of a Fokker 100 in Brasília

Date & Time: Mar 28, 2014 at 1742 LT
Type of aircraft:
Operator:
Registration:
PR-OAF
Survivors:
Yes
Schedule:
Petrolina – Brasília
MSN:
11415
YOM:
1992
Flight number:
OC6393
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4993
Captain / Total hours on type:
3060.00
Copilot / Total flying hours:
3357
Copilot / Total hours on type:
2844
Aircraft flight hours:
44449
Aircraft flight cycles:
32602
Circumstances:
The aircraft took off from the Senador Nilo Coelho Aerodrome (SBPL), Petrolina - PE, to Presidente Juscelino Kubitschek International Airport (SBBR), Brasilia - DF, at 1752 (UTC), in order to complete the scheduled cargo and personnel flight O6 6393, with 5 crewmembers and 44 passengers on board. During the level flight, thirty minutes after takeoff, the aircraft presented low level in the hydraulic system 1. The crew performed the planned operational procedures and continued the flight to Brasilia, with the hydraulic system degraded. During the SBBR landing procedures, the crew used the alternative system for lowering the landing gears. The main landing gears lowered and locked, the nose landing gear unlocked, but did not lower. After coordination with the air traffic control, the aircraft was instructed to land on SBBR runway 11R. The landing took place at 2042 (UTC). After the touchdown, the aircraft covered a total distance of 900 meters until its full stop. The initial 750 meters were with the aircraft supported only by the main landing gears and the last 150 meters were with the aircraft supported by the main landing gears and by the lower part of the front fuselage. The aircraft stopped on the runway. Substantial damage to structural elements of the aircraft occurred near the nose section. The evacuation of the crewmembers and passengers was safe and orderly. The copilot suffered fractures in the thoracic spine. The other crewmembers and passengers left unharmed.
Probable cause:
The following findings were identified:
- It was found that there was a restriction on the articulation movement of the right nose landing gear door and that the weight of this landing gear was not sufficient to overcome such restriction.
Upon inspecting the hinges, it was found that there were no signs of recent lubrication, allowing the hypothesis of occurrence of any deviation or non-adherence to the inspection and lubrication requirements established by the manufacturer leading to a the scenario favorable to the right door movement restriction. The issue of the maintenance could also be related to some deviation, or nonadherence to the requirements established for the service of widening the holes of the hinges concerning the coating and corrosion protection of the worked surface. As a result, the area could have been more susceptible to corrosive processes.
- The maintenance program, established by the manufacturer, may have contributed to the occurrence by not establishing adequate preventive maintenance parameters for the landing gear doors that were modified by reworking the hinges, incorporating larger radial pins and widening the lobe holes.
- It was not possible to determine the causal root of the EDP1 gasket extrusion, which caused the leakage of hydraulic oil that caused the hydraulic system 1 to fail.
Final Report:

Crash of a Cessna T303 Crusader in Barcelonnette

Date & Time: Mar 15, 2014 at 0945 LT
Type of aircraft:
Operator:
Registration:
N303W
Flight Type:
Survivors:
Yes
Schedule:
Cannes – Barcelonnette
MSN:
303-00227
YOM:
1983
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3950
Captain / Total hours on type:
280.00
Circumstances:
Following an uneventful flight from Cannes-Mandelieu Airport, the pilot initiated the approach to Barcelonnette-Saint-Pons Airport Runway 27. Following an unstabilized approach, the aircraft landed hard, causing the left main gear to collapse. The aircraft veered off runway to the left, lost its right main gear and came to rest. There was no fire. All five occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The accident was the consequence of the decision of the pilot to continue an unstabilized approach, resulting in a hard landing and the rupture of the left main gear upon touchdown.
Final Report:

Crash of a Cessna 402B in Stuart

Date & Time: Mar 14, 2014 at 1730 LT
Type of aircraft:
Operator:
Registration:
N419AR
Flight Type:
Survivors:
Yes
Schedule:
Fort Pierce - Stuart
MSN:
402B-0805
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
5860
Circumstances:
According to the pilot, he checked the fuel gauges before departure and believed he had enough fuel for the flight. As he approached his destination airport, he was instructed by an air traffic controller to enter a 2-mile left base. About 3 miles from the airport, the controller advised him to intercept a 6-mile final. About 1 1/2 miles from the runway, the left engine “quit.” The pilot repositioned the fuel valve to the left inboard fuel tank and was able to restart the engine, but, shortly after, the right engine “quit.” He then attempted to reposition the right fuel valve to the right inboard fuel tank to restart the right engine, but the left engine “quit” again, and the pilot subsequently made a forced landing in a field. An examination of the engine and airplane systems revealed no anomalies that would have precluded normal operation. The left wing fuel tanks were found empty. The right wing was found separated from the fuselage. No evidence of fuel was noted in the right wing fuel tanks, and no evidence of fuel leakage was found at the accident site. The pilot reported that he saw fuel leaking out of the right wing fuel vent after the accident; it is possible that a small quantity of the airplane’s unusable fuel for the right tank could have leaked out immediately after the accident. Although the pilot believed that the airplane had enough fuel onboard for the flight, his assessment was based on his calculations of the airplane’s fuel burn during several short flights he made after having the airplane topped off with fuel the night before the accident; he did not visually check the fuel level in the tanks before departing on the accident flight. The lack of fuel in the fuel tanks, the lack of evidence of fuel leakage, the loss of engine power in both engines, and the lack of mechanical anomalies are consistent with fuel exhaustion.
Probable cause:
The pilot’s improper preflight planning and fuel management, which resulted in a total loss of power in both engines due to fuel exhaustion.
Final Report:

Crash of a Beechcraft C90 King Air in Villavicencio: 5 killed

Date & Time: Mar 12, 2014 at 0633 LT
Type of aircraft:
Operator:
Registration:
HK-4921
Flight Type:
Survivors:
No
Schedule:
Bogotá – Araracuara
MSN:
LJ-721
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3013
Captain / Total hours on type:
538.00
Copilot / Total flying hours:
1341
Copilot / Total hours on type:
483
Aircraft flight hours:
9656
Circumstances:
The twin engine aircraft departed Bogotá-El Dorado Airport at 0600LT on an ambulance flight to Araracuara, State of Caquetá, carrying two doctors, one patient and two pilots. Fifteen minutes into the flight, the crew contacted ATC, reported problems and was cleared to divert to Villavicencio. On approach to Villavicencio-La Vanguardia Airport, the aircraft stalled and crashed in a wooded area parallel to a road, bursting into flames. The aircraft was destroyed by a post crash fire and all five occupants were killed.
Probable cause:
The following factors were identified:
- The lack of technical knowledge published in the POH for the execution of the pertinent actions during the failure of the engine in flight, together with the unwise decisions made by the crew in that situation.
- The haste of the crew members to land caused them to act in an uncoordinated manner and without the assertiveness required for the execution of the procedures contemplated by the manufacturer, the navigation charts and the published approach procedures.
- The omissions, reactions and deviations inappropriate to conduct the flight safely to the runway.
- The turning to the runway on the same side of the inoperative (critical) engine and maximum power on the operational engine during the unstabilized approach to the runway threshold which led to loss of control of the aircraft in low altitude flight.
Final Report:

Crash of an ATR42-300 in Churchill

Date & Time: Mar 9, 2014 at 1015 LT
Type of aircraft:
Operator:
Registration:
C-FJYV
Survivors:
Yes
Schedule:
Thompson – Churchill
MSN:
216
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Thompson, the crew completed the approach and landing at Churchill Airport. After touchdown, the crew started the braking procedure and was vacating the runway when the right main gear collapsed. This caused the right propeller and the right wing to struck the ground. The aircraft was stopped and all five occupants evacuated safely. The aircraft was damaged beyond repair.
Probable cause:
Failure of the right main gear for unknown reasons.