Landing (descent or approach)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Kota Kinabalu - Kudat

MSN:

804

YOM:

1983

Flight number:

MWG3002

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4700

Aircraft flight hours:

56828

Aircraft flight cycles:

108882

Circumstances:

A de Havilland Canada DHC-6 Twin Otter 310, operated by MASwings, sustained substantial damage in an accident at Kudat Airport (KUD), Malaysia. The copilot and one passenger died, four others were injured. MASwings flight MH3002 operated on a domestic flight from Kota Kinabalu Airport (BKI) to Kudat. The captain was the pilot flying for this sector and the first officer was pilot monitoring. As the aircraft was approaching Kudat Airfield, Kudat Tower reported the weather conditions to be: wind at 270 degrees at 17 kts gusting 31 kts. The aircraft continued the approach on runway 04 and leveled off at 500 feet with flaps set at 10°. At this point the crew noticed that the approach for runway 04 had a strong tail wind. This was evident from the indicated airspeed observed by the crew which indicated 100 kts where the airspeed for flaps 10° should be 65kts. The windsock also indicated a tail wind. Noticing the approach for runway 04 was a tail wind condition, the crew decided to go around at a height of 500ft. Maintaining runway heading, the crew initiated a go around climbing to 1,000ft making a left tear drop and reposition for runway 22. On the approach for runway 22 the captain informed the first officer that if they could not land they would return to Kota Kinabalu. The aircraft was aligned with the centerline of runway 22 and 20° flaps was set. The aircraft continued to descend to 300ft. At this point the wind appeared to be calm as the aircraft did not experience any turbulence and the captain told the first officer that he was committed to land. Upon reaching 200ft the captain called for the flaps to be lowered to full down. As they were about to flare the aircraft to land, approximately 20ft above the runway, the aircraft was suddenly hit by a gust of wind which caused the aircraft to veer to the right with the right wing low and left wing high and the nose was pointing 45° to the right of runway 22. The crew decided to go around by applying maximum power; however the aircraft did not manage to climb successfully. The flaps were not raised and were still in the full flaps down position as the crew thought the aircraft was still low hence the flaps were not raised. The aircraft continued to veer to the right with right wing low and managed to only climb at a shallow rate. The aircraft failed to clear the approaching trees ahead and was unable to continue its climb because the airspeed was reducing. The presence of a full flaps configuration made it more difficult for the aircraft to climb. As the aircraft was on full power on both the engines, it continued to fly almost perpendicularly in relation to the runway and at a low height above the ground. The aircraft hit a tree top at the airfield perimeter fencing, disappeared behind the row of trees, hit another tree behind a house. It hit the right rear roof of the house, ploughed through the roof top of the kitchen, toilet and dining area, hit the solid concrete pillars of the car garage and finally hit the lamp post just outside the house fence. It swung back onto the direction of the runway and came to rest on the ground with its left engine still running. A woman and her 11-year old son who were in the living room at the time escaped unhurt.

Probable cause:

Based on the information from the recorded statements of witnesses and Captain of the aircraft, it clearly indicates that the aircraft was attempting to land on Runway 04 with a tail-wind blowing at 270° 15kts gusting up to 25kts on the first approach, contrary to what was reported by the Captain to the investigators. The demonstrated cross wind landing on the DHC6-310 is 25kts and tailwind landing is 10kts. The aircraft was unsettled and unstable until it passed abeam the terminal building which was not the normal touch down point under normal landing condition. The flap setting on the first approach with the tail-wind condition was at 10°, which is not in accordance with company’s procedures. A tail wind landing condition that will satisfy the criteria for the DHC6-310 is not more than 10kts tail-wind and a flap setting of not more than 20°. One of the stabilized approach criterias for visual conditions (VMC) into Kudat is landing configuration must be completed by 500ft Above Ground Level (AGL) for the DHC6-310 where else if the above conditions could not be met, a go-around should be initiated. Hence, the Crew should have initiated a go-around earlier before the aircraft reached 500ft AGL on the first approach. The aircraft should be in the correct landing configuration at or below the stabilized approach altitude of 500ft AGL, since the aircraft was not stable due to the tail wind and gusting weather. The procedure carried out on the approach for Runway 04 was not consistent with MASwings’ Standard Operating Procedure (SOP) for a tailwind condition. Nonetheless, the first approach for Runway 04 though was uneventful. On the second approach from Runway 22, the wind condition was still not favorable for landing, and gusting. The aircraft was believed to be slightly low on the initial approach and was still unstable. The flap setting for the second approach for Runway 22 was at full flap (37°). As the wind was gusting, a flap setting to full-down should be avoided for the landing as stated in company’s DHC6-310 SOP. With the full-flap configuration, the aircraft had difficulty to settle down on the runway thus dragging the aircraft until abeam the tower which is way beyond the normal touch down zone.
At the point where the aircraft was approaching to land it was reported that the aircraft was hit by a sudden gust, several factors, including the following, have been looked into:
a) Why was the aircraft unable to climb after initiating the go-around?
The full flap setting would require a zero degree pitch attitude to ensure the aircraft speed is maintained. With go-around power set, the zero degree pitch would ensure a climb without speed loss. A pitch above zero degree can cause the aircraft speed to decrease and induce a stall condition resulting in the aircraft being unable to climb.
b) Was the go-around technique executed correctly, taking into consideration that the wind was blowing from 270° and gusting?
The Captain had said that "I applied maximum power and expected the aircraft to climb. At this point, the aircraft was still in left-wing high situation. I noticed the aircraft did make a climb but it was a shallow climb. I did not retract the flaps to 20°, as at that time, in my mind, the aircraft was still low."
c) Under normal conditions, the rule of thumb for initiating a go-around procedure is to apply maximum power, set attitude to climb, confirm airspeed increasing and reduce the flap setting. This procedure was found not to be properly synchronized between MASwings Manuals and DHC6-310 Series 300 SOP.
d) Were the pilots in control of the aircraft?
Based on the Captain’s statement and other associated factors, the pilots were not in total control of the aircraft.

Crash of a Cessna 340A in Hampton Roads: 4 killed

Date & Time: Oct 10, 2013 at 1209 LT

Type of aircraft:

Cessna 340

Operator:

Stephen George

Registration:

N4TK

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Schedule:

Fort Lauderdale – Hampton Roads

MSN:

340A-0777

YOM:

1979

Location:

Hampton Roads-Executive

Virginia

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The instrument-rated pilot was on a cross-country flight. According to air traffic control records, an air traffic controller provided the pilot vectors to an intersection to fly a GPS approach. Federal Aviation Administration radar data showed that the airplane tracked off course of the assigned intersection by 6 nautical miles and descended 800 ft below its assigned altitude before correcting toward the initial approach fix. The airplane then crossed the final approach fix 400 ft below the minimum crossing altitude and then continued to descend to the minimum descent altitude, at which point, the pilot performed a missed approach. The missed approach procedure would have required the airplane to make a climbing right turn to 2,500 ft mean sea level (msl) while navigating southwest back to the intersection; however, radar data showed that the airplane flew southeast and ascended and descended several times before leveling off at 2,800 ft msl. The airplane then entered a right 360-degree turn and almost completed another circle before it descended into terrain. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures. During the altitude and heading deviations just before impact, the pilot reported to an air traffic controller that adverse weather was causing the airplane to lose "tremendous" amounts of altitude; however, weather radar did not indicate any convective activity or heavy rain at the airplane's location. The recorded weather at the destination airport about the time of the accident included a cloud ceiling of 400 ft above ground level and visibility of 3 miles. Although the pilot reported over 4,000 total hours on his most recent medical application, the investigation could not corroborate those reported hours or document any recent or overall actual instrument experience. In addition, it could not be determined whether the pilot had experience using the onboard GPS system, which had been installed on the airplane about 6 months before the accident; however, the accident flight track is indicative of the pilot not using the GPS effectively, possibly due to a lack of proficiency or familiarity with the equipment. The restricted visibility and precipitation and maneuvering during the missed approach would have been conducive to the development of spatial disorientation, and the variable flightpath off the intended course was consistent with the pilot losing airplane control due to spatial disorientation. Toxicological tests detected ethanol and other volatiles in the pilot's muscle indicative of postmortem production.

Probable cause:

The pilot's failure to maintain airplane control due to spatial disorientation in low-visibility conditions while maneuvering during a missed approach. Contributing to the accident was the pilot's ineffective use of the onboard GPS equipment.

Final Report:

Crash of a PZL-Mielec AN-2T in Skulyn: 2 killed

Date & Time: Oct 10, 2013 at 0440 LT

Type of aircraft:

PZL-Mielec AN-2

Operator:

Registration:

UR-54853

Flight Phase:

Flight Type:

Illegal (smuggling)

Survivors:

Site:

Plain, Valley

MSN:

1G108-64

YOM:

1969

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew was performing an illegal flight, maybe from Belarus, with an important load of Belarusian cigarettes on board. By night, while approaching an unused airfield, the single engine aircraft impacted ground and crashed in an open field. There was no fire. The aircraft was destroyed and both occupants were killed. The registration UR-54853 was announced to be illegal as it was already involved in an accident in Ukraine on 07FEB2013. The registration SP-AOD was still painted on the lower left wing, and the aircraft was operated since Summer 2013 illegally with the UR-54853 registration.

Crash of a Britten BN-2A-8 Norman Islander off Culebra: 1 killed

Date & Time: Oct 6, 2013 at 0603 LT

Type of aircraft:

Britten-Norman Islander

Operator:

Registration:

N909GD

Flight Phase:

Cessna 525 CitationJet CJ2

Flight Type:

Cargo

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Vieques - Culebra

MSN:

239

YOM:

1971

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

1650

Captain / Total hours on type:

1100.00

Aircraft flight hours:

22575

Circumstances:

The commercial, instrument-rated pilot of the multiengine airplane was conducting a newspaper delivery flight in night visual meteorological conditions. After two uneventful legs, the pilot departed on the third leg without incident. Radar data indicated that, after takeoff, the airplane flew over open water at an altitude of about 100 to 200 ft toward the destination airport and then climbed to 2,400 ft. Shortly thereafter, the pilot performed a 360-degree left turn, followed by a 360-degree right turn while the airplane maintained an altitude of about 2,400 ft, before continuing toward the destination airport. Less than 2 minutes later, the airplane began a rapid descending left turn and then collided with water. The wreckage was subsequently located on the sea floor near the airplane's last radar target. Both wings, the cabin, cockpit, and nose section were destroyed by impact forces. The wreckage was not recovered, which precluded its examination for preimpact malfunctions. The airplane had been operated for about 25 hours since its most recent inspection, which was performed about 3 weeks before the accident. The pilot had accumulated about 1,650 hours of total flight experience, which included about 1,100 hours in the accident airplane make and model. Although the pilot conducted most of his flights during the day, he regularly operated flights in night conditions. The pilot's autopsy did not identify any findings of natural disease significant enough to have contributed to the accident. In addition, although toxicological testing detected ethanol in the pilot's cavity blood, it likely resulted from postmortem production.

Probable cause:

The pilot's failure to maintain airplane control for reasons that could not be determined because the wreckage was not recovered.

Final Report:

Crash of a Cessna 525A CitationJet CJ2 in Santa Monica: 4 killed

Date & Time: Sep 29, 2013 at 1820 LT

Type of aircraft:

Operator:

CREX-MML

Registration:

N194SJ

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Schedule:

Hailey - Santa Monica

MSN:

525A-0194

YOM:

2003

Location:

Santa Monica

California

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3463

Captain / Total hours on type:

1236.00

Aircraft flight hours:

1932

Circumstances:

The private pilot was returning to his home airport; the approach was normal, and the airplane landed within the runway touchdown zone markings and on the runway centerline. About midfield, the airplane started to drift to the right side of the runway, and during the landing roll, the nose pitched up suddenly and dropped back down. The airplane veered off the runway and impacted the 1,000-ft runway distance remaining sign and continued to travel in a righthand turn until it impacted a hangar. The airplane came to rest inside the hangar, and the damage to the structure caused the roof to collapse onto the airplane. A postaccident fire quickly ensued. The subsequent wreckage examination did not reveal any mechanical anomalies with the airplane's engines, flight controls, steering, or braking system. A video study was conducted using security surveillance video from a fixed-base operator located midfield, and the study established that the airplane was not decelerating as it passed through midfield. Deceleration was detected after the airplane had veered off the runway and onto the parking apron in front of the rows of hangars it eventually impacted. Additionally, video images could not definitively establish that the flaps were deployed during the landing roll. However, the flaps were deployed as the airplane veered off the runway and into the hangar, but it could not be determined to what degree. To obtain maximum braking performance, the flaps should be placed in the ”ground flap” position immediately after touchdown. The wreckage examination determined that the flaps were in the ”ground flap” position at the time the airplane impacted the hangar. Numerous personal electronic devices that had been onboard the airplane provided images of the passengers and unrestrained pets, including a large dog, with access to the cockpit during the accident flight. Although the unrestrained animals had the potential to create a distraction during the landing roll, there was insufficient information to determine their role in the accident sequence or what caused the delay in the pilot’s application of the brakes.

Probable cause:

The pilot’s failure to adequately decrease the airplane’s ground speed or maintain directional control during the landing roll, which resulted in a runway excursion and collision with an airport sign and structure and a subsequent postcrash fire.

Final Report:

Crash of a Beechcraft C90A King Air in Idaho Falls

Date & Time: Sep 19, 2013 at 1553 LT

Type of aircraft:

Beechcraft 90 King Air

Operator:

We Fly

Registration:

N191TP

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Pocatello – Idaho Falls

MSN:

LJ-1223

YOM:

1989

Location:

Idaho Falls

Idaho

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3975

Captain / Total hours on type:

2500.00

Aircraft flight hours:

4468

Circumstances:

The airplane was equipped with two main fuel tanks (132 usable gallons each) and two nacelle fuel tanks (60 usable gallons each). In normal operation, fuel from each nacelle tank is supplied to its respective engine, and fuel is automatically transferred from each main tank to its respective nacelle tank. While at the airplane's home airport, the pilot noted that the cockpit fuel quantity gauges indicated that the nacelle tanks were full, and he believed that the main tanks had fuel sufficient for 30 minutes of flight. The pilot did not verify by any other means the actual fuel quantity in any of the tanks. Thirty gallons of fuel were added to each main tank; they were not topped off. The airplane, with two passengers, then flew to an interim stop about 45 miles away, where a third passenger boarded. The airplane then flew to its destination, another 165 miles away. The pilot reported that, at the destination airport, he noted that the cockpit fuel quantity gauges indicated that the nacelle tanks were full; he surmised that the main fuel tanks were not empty but did not note the actual quantity of fuel. Forty gallons of fuel were added to each main tank. Again, the main tanks were not topped off, and the pilot did not verify by any other means the actual fuel quantity in any of the tanks. The return flight to the interim stop was uneventful. The third passenger deplaned there, and the airplane departed for its home airport. While on final approach to the home airport, both engines stopped developing power, and the pilot conducted a forced landing to a field about 1.2 miles short of the runway. The pilot later reported that, at the time of the power loss, the fuel quantity gauges indicated that there was still fuel remaining in the airplane. Postaccident examination of the airplane revealed that all four fuel tanks were devoid of fuel. The examination did not reveal any preimpact mechanical anomalies, including fuel leaks, that would have precluded continued flight. The airplane manufacturer conducted fuel-consumption calculations for each of the two city pairs. Because the pilot did not provide any information regarding flight routes, altitudes, speeds, or times for any of the flight segments, the manufacturer's calculations were based on direct routing in zero-wind conditions, nominal airplane and engine performance, and assumed cruise altitudes and speeds. Although the results are valid for these input parameters, variations in any of the input parameters can significantly affect the calculated fuel requirements. As a result, although the manufacturer's calculations indicated that the round trip would have burned less fuel than the total available fuel quantity that was derived from the pilot-provided information, the lack of any definitive information regarding the actual flight parameters limited the utility of the calculated value and the comparison. The manufacturer's calculations indicated that the accident flight leg (from the interim airport to the home airport) would have consumed about 28.5 gallons total. Given that the airplane was devoid of fuel at the accident site, the pilot likely departed the interim airport with significantly less than the manufacturer's minimum allowable departure fuel quantity of about 39.5 gallons per side. The lack of any observed preimpact mechanical problems with the airplane, combined with the lack of objective or independently substantiated fuel quantity information, indicates that the airplane's fuel exhaustion was due to the pilot's inadequate and improper pre- and inflight fuel planning and procedures.

Probable cause:

The pilot's inadequate preflight fuel planning, which resulted in departure with insufficient fuel to complete the flight, and consequent inflight power loss due to fuel exhaustion.

Final Report:

Crash of a PZL-Mielec AN-2R in Kamako

Date & Time: Sep 13, 2013 at 1150 LT

Type of aircraft:

PZL-Mielec AN-2

Operator:

Registration:

9Q-CFT

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Democratic Republic of Congo

Schedule:

Tshikapa - Kamako

MSN:

1G223-14

YOM:

1987

Location:

Kamako

Kasai-Occidental

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

16798

Captain / Total hours on type:

16000.00

Aircraft flight hours:

6981

Circumstances:

Following an uneventful flight from Tshikapa, the pilot initiated the approach to Kamako Airfield in relative good conditions. On final, the wind component suddenly changed. The aircraft lost height and impacted ground 16 metres short of runway 12. Upon impact, the undercarriage were partially torn off and the aircraft slid before coming to rest 37 metres past the runway threshold. All six occupants, one pilot and five passengers, escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

It was determined that the loss of control that occurred on short final was the result of the combination of a human error and weather component. The pilot was surprised by the abrupt change in weather conditions on short final to Kamako runway 12. He elected to initiate a go-around procedure and increased engine power but unfortunately, low level windshear caused the aircraft to lose height and to struck the ground as its speed was insufficient. In consequence, the increase power was too low to allow the pilot to maintain the approach profile. The torsion of the blades confirmed that the engine was at full power for a go-around procedure at impact. The absence of a windsock at Kamako Airfield was considered as a contributing factor as this would help the pilot to recognize the wind component and to decide to land or to go-around in due time.

Final Report:

Crash of a Dornier DO228-202K in Viña del Mar: 2 killed

Date & Time: Sep 9, 2013 at 0950 LT

Type of aircraft:

Dornier DO228

Operator:

Registration:

CC-CNW

Flight Phase:

Flight Type:

Positioning

Survivors:

Site:

Schedule:

Coquimbo - Viña del Mar

MSN:

8063

YOM:

1986

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

15537

Captain / Total hours on type:

12431.00

Copilot / Total flying hours:

10777

Aircraft flight hours:

25012

Circumstances:

The crew departed Coquimbo on a positioning flight to Viña del Mar to pick up passengers who need to fly to a mining area located in Los Perlambres. As the ILS system was inoperative, the crew was forced to complete a non-precision approach to runway 05. The visibility was poor due to foggy conditions. On final approach, while the aircraft was unstable, the crew descended below the MDA until the aircraft collided with power cables and crashed in an open field located about 1,8 km short of runway. The aircraft was destroyed upon impact and both pilots were killed.

Probable cause:

Controlled flight into terrain following the decision of the crew to continue the approach below the MDA without visual contact with the runway until the aircraft impacted ground.
The following contributing factors were identified:
- Failure to apply the concepts of Crew Resource Management (CRM).
- Failure to use checklists.
- Failure to brief the maneuvers to be executed.
- Loss of situational awareness of the crew.
- Failure to keep a sterile cockpit during approach.
- Complacency and overconfidence of the pilots.
- Unstabilized instrument approach.
- Lack and/or non-use of equipment and systems to support the flight.

Final Report:

Crash of an Airbus A330-321 in Bangkok

Date & Time: Sep 8, 2013 at 2326 LT

Type of aircraft:

Airbus A330

Operator:

Registration:

HS-TEF

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site: