Landing (descent or approach)

The Twin Otter (DHC6/300) aircraft with registration number 9N-ABO, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu to Pokhara for night stop on 15 May 2013 in order to accomplish up to 5 (five) Pokhara-Jomsom-Pokhara charter flights planned for the subsequent day on 16 May 2013. As per the programme, the aircraft completed first charter flight from Pokhara to Jomsom sector on 16 May 2013 morning after one and half hour waiting on ground due weather. For this second flight, the aircraft departed at 0225 UTC (08:10LT) from Pokhara to Jomsom in the command of Capt. Dipendra Pradhan and Mr. Suresh K.C. as co-pilot. There were 19 passengers including one infant and 3 crew members on board. The aircraft was operating under Visual Flight Rules (VFR). As per the CVR readout there was no reported difficulties and all the pre and post departure procedure and en-route portion of the flight were completed in normal manner. There was no indication of lacking of information and advice from Jomsom Tower. At first contact the co-pilot called Jomsom Tower and reported its position at PLATO (a compulsory reporting point) at 9 miles from Jomsom airport at 12500ft. AMSL. The Jomsom Tower advised runway 24 wind south westerly 08-12 KTS, QNH 1020, Temp 13 degree and advised to report downwind for runway 24.The co-pilot accepted by replying to join downwind for runway 24. There was no briefing and discussion between the two pilots regarding the tail wind at the airport. The PIC, then, took over the communication function from co-pilot and called Jomsom Tower, requesting to use runway 06 instead of runway 24, despite the advice of tower to use runway 24 to avoid tail wind effect in runway 06. Jomsom Tower repeated the wind speed to be 08-12 KTS for the runway 06, to which the PIC read back the wind and answered to have ”no problem”. As per the PIC request the Jomsom Tower designated runway 06 for landing and advised to report on final runway 06. The PIC did read back the same. The pre landing checklist was used, flaps with full fine in propeller rpm were taken and full flaps was also taken before touchdown. In the briefing of “missed approach” the PIC had answered to be “standard”. The aircraft touched down runway of Jomsom airport at 0245 UTC (08:30LT) at a distance of approximately 776 ft, far from the threshold of runway 06. After rolling 194 ft. in the runway, the aircraft left runway and entered grass area in the right side. The aircraft rolled around 705 ft in the grass area and entered the runway again. The maximum deviation from the runway edge was 19 ft. The Commission has observed that when aircraft touched down the runway, it was not heading in parallel to the runway centreline. After touchdown the aircraft rolled around 194ft on the runway, left the paved area and started rolling in the grass area in the right side. During the landing roll, when the aircraft was decelerating, the co-pilot had raised the flaps as per the existing practice of carrying out “after the landing “checks". As per the observation of passenger seated just behind the cockpit, after touchdown of the aircraft there was no communication between pilot and co-pilot. It seemed that pilot was busy in cockpit and facing problem. It was obvious that PIC was in dilemma in controlling aircraft. He added power to bring aircraft into the runway with an intention to lift up the aircraft. He did not brief anything to copilot about his intention and action. He started adding power with the intention of lifting up, but the aircraft was already losing its speed, due to extension of flaps by co-pilot without briefing to PIC and use of brakes (light or heavy, knowingly and unknowingly) simultaneously by the PIC. The accelerating aircraft with insufficient speed and lift to take off ran out of the runway 24 end, continued towards the river, hit the barbed fence and gabion wall with an initial impact and finally fell down into the edge of river. The left wing was rested in the mid of the river preventing the aircraft submerged into the river.

The crew of the twinjet reported that the positioning flight after maintenance was uneventful. However, during the landing roll at their home base, the thrust reversers, steering, and braking systems did not respond. As the airplane approached the end of the runway, the pilot activated the emergency braking system; however, the airplane overran the end of the runway, coming to rest in a ditch. None of the three occupants were injured, but the airplane sustained substantial damage to both wings and the fuselage. Two squat switches provided redundancy within the airplane’s electrical system and were configured to prevent inadvertent activation of the thrust reversers and nosewheel steering during flight and to prevent the airplane from landing with the brakes already applied. Because postaccident examination revealed that the squat switch assemblies on the left and right landing gear struts were partially detached from their mounting pads such that both switches were deactivated, all of these systems were inoperative as the airplane landed. The switch assemblies were undamaged, and did not show evidence of being detached for a long period of time. The brakes and steering were working during taxi before departure, but this was most likely because either one or both of the switches were making partial contact at that time. Therefore, it was most likely that the squat switch assemblies were manipulated on purpose during maintenance in an effort to set the airplane’s systems to “air mode.” Examination of the maintenance records did not reveal any recent procedures that required setting the airplane to air mode, and all mechanics involved in the maintenance denied disabling the switches. Mechanics did, however, miss two opportunities to identify the anomaly, both during the return-to-service check and the predelivery aircraft and equipment status check. The anomaly was also missed by the airplane operator’s mechanic and flight crew who performed the preflight inspection. The airplane’s emergency braking system was independent of the squat switches and appeared to operate normally during a postaccident test. Prior to testing, it was noted that the emergency brake gauge indicated a full charge; therefore, although evidence suggests that the emergency brake handle was used, it was not activated with enough force by the pilot. The pilot later conceded this fact and further stated that he should have used the emergency braking system earlier during the landing roll. The airplane was equipped with a cockpit voice recorder (CVR), which captured the entire accident sequence. Analysis revealed that the airplane took just over 60 seconds to reach the runway end following touchdown, and, during that time, two attempts were made by the pilot to activate the thrust reversers. The pilot stated that as the airplane approached the runway end, the copilot made a third attempt to activate the thrust reversers, which increased the engine thrust, and thereby caused the airplane to accelerate. Audio captured on the CVR corroborated this statement.

On final approach to Valencia-Arturo Michelana Airport in marginal weather conditions, the aircraft crashed in a residential area some 2,055 metres short of runway. The aircraft was totally destroyed by impact forces and a post impact fire and both pilots were killed. A building, several houses and cars were also damaged by fire.

The single engine aircraft departed Kiel-Holtenau Airport in the morning, carrying two passengers and two pilots, bound for Rotenburg, Lower Saxony, where two additional passengers should embark before continuing to Friedrichshafen to take part to the Aero 2013 Airshow. On approach to Rotenburg-Wümme Airport, the crew encountered poor weather conditions with a cloud base at 500 feet and a visibility limited to 2 km. On final approach, the aircraft impacted ground and came to rest in an open field, bursting into flames. The burnt wreckage was found 2,3 km short of runway 08 and 570 metres to the left of its extended centerline. The aircraft was destroyed by a post crash fire and all four occupants were killed.

On 13 April 2013, a Boeing 737-800 aircraft, registered PK-LKS, was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung at 0545 UTC to Ngurah Rai International Airport (WADD), Bali, Indonesia. The flight was the last sector of four legs scheduled for the crew on that day which were Palu (WAML) - Balikpapan (WALL) - Banjarmasin (WAOO) - Bandung (WICC) - Bali (WADD). The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). There were 2 pilots, 5 flight attendants and 101 passengers comprising 95 adults, 5 children and 1 infant making a total of 108 persons on board. The flight from the departure until start of the approach into Bali was uneventful. At 0648 UTC, the pilot made first communications with the Bali Approach controller (Bali Director) when the aircraft was located 80 Nm from BLI VOR. The pilot received clearance to proceed direct to the TALOT IFR waypoint and descend to 17,000 feet. At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA point and descent to 8,000 feet. At 0659 UTC, the aircraft was vectored for a VOR DME approach for runway 09 and descent to 3,000 feet. At 0703 UTC, while the aircraft was over KUTA point, the Bali Director transferred communications with the aircraft to Bali Control Tower (Ngurah Tower). At 0704 UTC, the pilot contacted Ngurah Tower controller and advised that the aircraft was leaving KUTA point. The Ngurah Tower controller instructed the pilot to continue the approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft. At 0707 UTC, the Ngurah Tower issued take-off clearance for a departing aircraft on runway 09. At 0708 UTC, with LKS at approximately 1,600 feet AGL, the Ngurah Tower controller saw the aircraft on final approach and gave a landing clearance with additional information that the wind was from 120° at 05 knots. At 0708:47 UTC, the aircraft Enhance Ground Proximity Warning System (EGPWS) aural alert called “ONE THOUSAND”, the SIC said one thousand, stabilized, continue, prepare for go-around missed approach three thousand. The FDR showed that the pilot flown using LNAV (Lateral Navigation) and VNAV (Vertical Navigation) during the approach until disengagement of the Auto Pilot. The sequence of events during the final approach is based on the recorded CVR and FDR data, and information from crew interviews as follows: At 0708:56 UTC, while the aircraft altitude was approximately 900 feet AGL, the SIC commented that the runway was not in sight, whereas the PIC commented “OK. Approach light in sight, continue”. At 0709:33 UTC, after the EGPWS aural alert “MINIMUM” sounded at an aircraft altitude of approximately 550 feet AGL, the SIC disengaged the autopilot and the auto-throttle and then continued the approach. At 0709:43 UTC, the EGPWS called “THREE HUNDRED”. At 0709:47 UTC, the CVR recorded a sound similar to rain hitting the windshield. At 0709:49 UTC, the EGPWS called “TWO HUNDRED”. At 0709:53 UTC, while the aircraft altitude was approximately 150 feet AGL, the PIC took over control of the aircraft. The SIC handed control to the PIC and stated that he could not see the runway. At 0710:01 UTC, after the EGPWS called “TWENTY”, the PIC commanded for go-around. At 0710:02 UTC, the aircraft impacted the water, short of the runway. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south-west of the beginning of runway 09. Between 0724 UTC to 0745 UTC, three other aircraft took-off and six aircraft landed using runway 09. At 0750 UTC, the airport was closed until 0850 UTC. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis centre.

The aircraft was completing a humanitarian flight to Doro Airfield, South Sudan, carrying four crew members and a load consisting of food. After landing, the aircraft went out of control, veered off runway, struck a drainage ditch and came to rest against an earth mound. All four occupants escaped uninjured while the aircraft was destroyed.

The aircraft was planned to fly from Lanseria airport (FALA) in Republic of South Africa to Bamako airport (GABS) in Mali with a stopover in Ondangwa airport (FYOA) in Namibia, São Tomé International airport (FPST) in São Tomé and Príncipe and Accra airport (DGAA) in Ghana, with a rough estimating time of approximately 15hrs flying, not including the ground time at airports of stopover. The aircraft had been in Lanseria airport (FALA) in Republic of South Africa (RSA) for maintenance check (including but not limited to engine work and interior refurbishing). Prior to the planned flight, the aircraft underwent flight check for 45 minutes after completed planned maintenance on Saturday, April 6th, flown by the Captain and another SAS company pilot. The aircraft departed FALA to FYOA for its first stop over whose flight time was 03:35h. The planned departure from FYOA was delayed due to trouble in starting the right engine. The aircraft took off at 1021hrs contrary to planned 0830hrs. For the second leg of the flight, the aircraft departed FYOA to FPST with filed flight plan of 05 hours and 20 minutes (flight time) having FYOA as alternate. Leaving the Namibian airspace the pilot only contacted Luanda ATC and São Tomé Tower as destination, and at no time did he contact Brazzaville or Libreville for any further clearance within Brazzaville FIR: It is important to emphasize that on that day, the west coast of Africa in the vicinity of Gulf of Guinea had widespread moderate to severe thunderstorm activity with lighting and heavy rain. When initiating descent to São Tomé from FL 200 to 4000 feet as instructed by São Tomé ATC, the pilot was advised that weather was gradually deteriorating at airport vicinity. At 1610hrs the pilot had last transmission with Control Tower informing them about his position which was 9 nm inbound to São Tomé VOR at 4000 feet and also informed the ATC that he was encountering heavy rain. Having lost contact with aircraft at 1613hrs, the São Tomé ATC tried several times to contact the airplane by VHF118.9, 127.5, 121.5 and HF 8903 without success. Facing this situation the ATC sent messages to FIRs of Brazzaville and Accra and Libreville Control as well, some airlines flying within São Tomean an adjacent airspace were contacted for any information but all responses were negative. A Search and Rescue operation started on 7 April 2013 the same day the accident occurred and was conducted on the sea and on the island; no trace of aircraft or its debris, pilot or any cargo were found. The search was terminated on 20 April at 1730hrs.

En route from Cuernavaca to Guadalajara, while in cruising altitude, the pilot informed ATC about technical problems with the right engine. He was cleared to divert to Morelia Airport for an emergency landing. On final approach to runway 05, the twin engine aircraft crashed in an open field located about 2 km short of runway. All six occupants evacuated with minor injuries and the aircraft was damaged beyond repair.

Aircraft was substantially damaged when it veered off the runway while landing at Hammonton Municipal Airport (N81), Hammonton, New Jersey. The private pilot was not injured and the commercial pilot-rated passenger received minor injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight. The flight originated from Montgomery County Airpark (GAI), Gaithersburg, Maryland about 1105 and was destined for N81. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was being repositioned to N81 in order for the owner's insurance adjuster and a local mechanic to physically inspect previous claim work for damage done during ground handling following Hurricane Sandy. The pilot reported lowering the landing gear during the approach to runway 03, and confirmed that they were extended by observing the landing gear position indicator lights. Immediately after touchdown, the airplane veered to the left. The pilot applied full right rudder, but the airplane continued to veer to the left. After departing the left side of the runway, the airplane struck several trees and was subsequently engulfed in a post-crash fire. According to FAA records, the pilot held a private certificate, with ratings for airplane single- and multiengine land. His most recent FAA third class medical certificate was issued on January 2, 2013. As of April 5, 2013, the pilot reported a total of 587 total hours of flight experience, of which 120 hours were in the same make and model as the accident airplane. The seven-seat, twin-engine, low-wing, retractable tricycle-gear airplane was manufactured in 1977 and was equipped with two Continental Motors TSIO-520, 520-hp engines. Review of the airplane's maintenance logbooks revealed that its most recent annual inspection was completed on October 26, 2012. At the time of inspection, the airplane had accumulated 9,335 total hours in service. The number one and two engines accumulated approximately 735 and 157 total hours of operation since overhaul, respectively. The airplane had flown about three hours since the most recent annual inspection. The 1154 recorded weather observation at Atlantic City International Airport (ACY), Atlantic City, New Jersey, located about 15 miles southeast of the accident site, included wind from 330 degrees at 13 knots, 10 miles visibility, few clouds at 1,600 feet, temperature 11 degrees C, dew point 4 degrees C, and a barometric altimeter setting of 29.83 inches of mercury. N81 was a non-tower-controlled airport equipped with one asphalt runway, oriented in a 03/21 configuration. The runway was 3,601 feet in length and 75 feet wide. The field elevation for the airport was 65 feet mean sea level.

On Thursday April 4, 2013 at approximately1:00AM DST (0500 UTC) a fixed wing, twin-engine, Cessna 402C aircraft Bahamas registration C6-BGJ, serial number 402C0106, crashed into obstacles (vehicles) while landing on Runway 06 at Mayaguana International Airport (MYMM), Abraham’s Bay, Mayaguana, Bahamas. The pilot in command stated that on April 3, 2013, he received a call at approximately 9:30PM from the Princess Margaret Hospital requesting emergency air ambulance services out of Mayaguana. The local police on the island was contacted to confirm lighting approval and availability in order to conduct the emergency flight. After confirming lighting arrangements with Nassau Air Traffic Control Services, and obtaining the necessary clearance, the pilot in command, along with a copilot and one passenger, (a nurse), proceeded with the flight to Mayaguana. The flight departed Lynden Pindling International Airport at approximately 1:30PM DST (0330UTC). The destination was Abraham’s Bay, Mayaguana, Bahamas. The pilot in command also reported “about 1 hour and 40 minutes later we arrived at Mayaguana Airport, leveled off at 1500 feet and about 4 miles left base Runway 06, we had the runway in sight via lighting from vehicles.” The crew continued with the landing procedures. The aircraft touch down approximately 300 feet from the threshold on runway 06, the pilot in command reported that prior to the nose gear making contact with the runway “the right wing hit an object (vehicle), causing the aircraft to veer out of control to the right eventually colliding with a second vehicle approximately 300 to 400 feet on the right side (southern) of Runway 06.” The impact of the right wing of the aircraft with the second vehicle, caused the right wing (outboard of the engine nacelle) and right fuel sealed wet wing tank to rupture releasing the aircraft fuel in that wing, which caused an explosion engulfing the vehicle in flames. The force of the impact with the second vehicle caused the right main gear to break away from the aircraft and it was flung ahead and to the left side of the runway approximately 200 feet from the point of impact with the truck. As the right main gear of the aircraft was no longer attached, the aircraft collapsed on its right side, slid onto the gravel south (right) of the runway and somewhere during this process, the nose gear also collapsed. The pilot immediately shut off the fuel valve of the aircraft and once the engines and the aircraft came to a stop, the three occupants evacuated the aircraft. The occupants of the aircraft did not sustain any visible injuries requiring medical attention or hospitalization. However, three (3) occupants of the second vehicle that was struck, were fatally injured. The airplane sustained substantial damages as a result of the impact and post impact crash sequence. The impact with the first vehicle occurred at approximately 427 feet from the threshold of runway 06 and at coordinates 28˚ 22’30”N and 073˚ 01’15’W. The flight was operated on an Instrument Flight Rules flight plan. Instrument Meteorological Conditions (night) prevailed at the time of the accident.