Crash of a Casa CN235-220 in Monrovia: 11 killed

Date & Time: Feb 11, 2013 at 0710 LT
Registration:
3X-GGG
Flight Type:
Survivors:
No
Schedule:
Conakry - Monrovia
MSN:
N014
YOM:
1991
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft was carrying a delegation of Senior Officials of the Guinea Air Force to Monrovia. On final approach to Roberts Airport, the aircraft descended too low, impacted trees and crashed in a wooded area located near Charlesville, some 4 km short of runway. The aircraft was destroyed by impact forces and a post crash fire and all 11 occupants were killed, among them General Souleymane Kéléfa Diallo, Chief of Staff of the Guinea Army Forces. The delegation was on its way to Monrovia to take part to the celebration of the Liberia Army forces anniversary.
Probable cause:
In July 2013, the investigation board confirmed that the accident resulted of multiple errors committed by the pilots who did not carry sufficient attention to the flight and the approach procedure. Investigators also concluded that the flight crew was tired, which was considered as a contributing factor because their faculties and capacities were diminished.

Crash of an Airbus A320-211 in Tunis

Date & Time: Feb 6, 2013 at 1423 LT
Type of aircraft:
Operator:
Registration:
TS-IMB
Survivors:
Yes
Schedule:
Casablanca - Tunis
MSN:
119
YOM:
1990
Flight number:
TU712
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
75
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Casablanca-Mohamed V Airport, the crew started the approach to Tunis-Carthage International Airport Runway 19 and encountered marginal weather conditions. After touchdown, the aircraft rolled for a distance of 1,600 metres then deviated to the right. The aircraft veered off runway, rolled in a grassy area for 114 metres when the nose gear impacted the concrete perpendicularly runway 11/29. On impact, the nose gear was torn off and the aircraft rolled for another 130 metres before coming to rest. All 83 occupants evacuated safely while the aircraft was damaged beyond repair. At the time of the accident, strong crosswinds and heavy rain falls passed over the airport.

Crash of a Beechcraft E90 King Air in Casa Grande: 2 killed

Date & Time: Feb 6, 2013 at 1135 LT
Type of aircraft:
Registration:
N555FV
Flight Type:
Survivors:
No
Schedule:
Marana - Casa Grande
MSN:
LW-248
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1079
Captain / Total hours on type:
112.00
Copilot / Total flying hours:
8552
Copilot / Total hours on type:
325
Aircraft flight hours:
8345
Circumstances:
The lineman who spoke with the pilot/owner of the accident airplane before its departure reported that the pilot stated that he and the flight instructor were going out to practice for about an hour. The flight instructor had given the pilot/owner his initial instruction in the airplane and flew with the pilot/owner regularly. The flight instructor had also given the pilot/owner about 58 hours of dual instruction in the accident airplane. The pilot/owner had accumulated about 51 hours of pilot-in-command time in the airplane make and model. It is likely that the pilot/owner was the pilot flying. Several witnesses reported observing the accident sequence. One witness reported seeing the airplane pull up into vertical flight, bank left, rotate nose down, and then impact the ground. One witness reported observing the airplane go from east to west, turn sharply, and then go north of the runway. He subsequently saw the airplane hit the ground. One witness, who was a pilot, stated that he observed the airplane enter a left bank and then a nose-down attitude of about 75 degrees at an altitude of about 300 feet above ground level, which was too low to recover. It is likely that the pilot was attempting a go-around and pitched up the airplane excessively and subsequently lost control, which resulted in the airplane impacting flat desert terrain about 100 feet north of the active runway at about the midfield point in a steep nose-down, left-wing-low attitude. The airplane was destroyed by postimpact forces and thermal damage. All components necessary for flight were accounted for at the accident site. A postaccident examination of the airframe and both engines revealed no anomalies that would have precluded normal operation. Additionally, an examination of both propellers revealed rotational scoring and twisting of the blades consistent with there being power during the impact sequence. No anomalies were noted with either propeller that would have precluded normal operation. Toxicological testing of the pilot was negative for drugs and alcohol. The flight instructor’s toxicology report revealed the presence of tetrahydrocannabinol (THC). Given the elevated levels of metabolite in the urine and kidney, the absence of quantifiable THC in the urine, and the low level of THC in the kidney and liver, it is likely that the flight instructor most recently used marijuana at least several hours before the accident. However, the effects of marijuana use on the flight instructor’s judgment and performance at the time of the accident could not be determined. A review of the flight instructor’s personal medical records indicated that he had a number of medical conditions that would have been grounds for denying his airman medical certificate. The ongoing treatment of his conditions with more than one sedating benzodiazepine, including oxazepam, simultaneously would also likely not have been allowed. However, none of the prescribed, actively sedating medications were found in the flight instructor’s tissues, and oxazepam was only found in the urine, which suggests that the flight instructor used the medication many hours and possibly several days before the accident. The toxicology findings indicate that the flight instructor likely did not experience any impairment from the benzodiazepine medication itself; however, the cognitive effects from the underlying mood disturbance could not be determined.
Probable cause:
The pilot’s loss of control of the airplane after pitching it excessively nose up during a go-around, which resulted in a subsequent aerodynamic stall/spin.
Final Report:

Crash of an ATR72-500 in Rome

Date & Time: Feb 2, 2013 at 2032 LT
Type of aircraft:
Operator:
Registration:
YR-ATS
Survivors:
Yes
Schedule:
Pisa - Rome
MSN:
533
YOM:
1997
Flight number:
AZ1670
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18552
Captain / Total hours on type:
3351.00
Copilot / Total flying hours:
624
Copilot / Total hours on type:
14
Aircraft flight hours:
24088
Circumstances:
The Rome-Fiumicino Airport Runway 25 was closed to trafic due to work in progress so the crew was vectored and cleared for a landing on runway 16L. The approach was completed in good visibility with strong crosswinds from 250° at 28 knots gusting to 41 knots and windshear. On the last segment, the aircraft lost height and impacted ground 567 metres short of runway 16L threshold. The aircraft bounced three times, lost its right main gear, slid for few dozen metres and came to rest in a grassy area some 1,780 metres past the runway threshold. All 50 occupants were rescued, among them seven were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The accident is due to the human factor. In particular, it was caused by an improper conduct of the aircraft by the PF (commander) during landing, not consistent with the provisions of the operator's manuals, in an environmental context characterized by the presence of significant criticality (presence of crosswind with values at the limit/excess those allowed for the ATR 72) and in the absence of an effective CRM.
The following factors may have contributed to the event:
- The failure to carry out the landing briefing, which, in addition to being required by company regulations, would have been an important moment of pooling and acceptance of information fundamental to the safety of operations.
- The maintenance of a V APP significantly higher than expected.
- The conviction of the commander (PF), deriving from his considerable general and specific experience on the aircraft in question, to be able to conduct a safe landing in spite of the presence of critical wind conditions for the type of aircraft.
- The considerable difference in experience between the commander and the first officer, which has reasonably prevented the latter from showing his critical capacity, thus rendering CRM techniques ineffective.
Final Report:

Crash of a Canadair RegionalJet CRJ-200ER in Almaty: 21 killed

Date & Time: Jan 29, 2013 at 1310 LT
Operator:
Registration:
UP-CJ006
Survivors:
No
Schedule:
Kokshetau - Almaty
MSN:
7413
YOM:
2000
Flight number:
VSV760
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
18194
Captain / Total hours on type:
1010.00
Copilot / Total flying hours:
3507
Copilot / Total hours on type:
132
Aircraft flight hours:
25707
Aircraft flight cycles:
22975
Circumstances:
Following an uneventful flight from Kokshetau, the crew started the descent to Almaty Airport and was cleared for an ILS approach (Cat IIIb approach) to runway 23R. At this time, the horizontal visibility was 200 metres, the vertical visibility 40 metres and the RVR for runway 23R was 275-250-225 metres respectively. Due to this poor weather conditions at destination, the captain got stressed, creating a strong emotional reaction. On short final, at an altitude of 180 metres, the captain decided to abandon the landing procedure and initiated a go-around manoeuvre. The automatic pilot system was deactivated and the TO/GA mode was activated. Four seconds later, the captain pushed the control column forward, causing the aircraft to descend. The EGPWS alarm sounded in the cockpit but there was no response from the flying crew. In a pitch angle of -16° and with a descent rate of about 20-30 metres per second, the aircraft impacted ground and disintegrated in a snow covered field. The wreckage was found some 1,400 metres short of runway. All 21 occupants were killed. Due to the actual weather conditions, the crew should perform a Cat IIIc approach.
Probable cause:
The accident with aircraft CRJ-200 UP-CJ006 occurred during the execution of a go-around, in instrument meteorological conditions, without the possibility of visual contact with ground reference points (vertical visibility in the fog did not exceed 40 m), the necessity of which was caused by the mismatch between the actual weather conditions and the minimum conditions for which the crew was certified to land. As a result, the deflection of the elevator towards a dive of the aircraft caused a descent and collision with the ground. It was not possible to uniquely identify the causes of the aircraft's transfer to a dive from the available data. The Commission did not find evidence of failures of aviation equipment, as well as external to the aircraft (icing, wind shear, wake turbulence) when trying to perform a go-around.
The most likely factors that led to the accident, were:
- Partial loss performance of the pilot in command, which at the time of aircraft impact with the ground was not in a working position;
- The lack of CRM levels in the crew, and violation of the Fly-Navigate-Communicate principle, which manifested itself in diverting attention by the co-pilot to conduct external radio communication and lack of control of the flight instrument parameters;
- The lack of response to the EGPWS and the actions required;
- The impact somatogravic illusions of perception of the pitch angle (a nose-up illusion);
- Increased emotional stress by the crew members associated with the unjustified expectations of improved weather conditions at the time of landing;
- Failure to comply with the requirements for health examination of flight personnel, which led to the pilot in command flying without the rehabilitation period and without assessment of his health status after undergoing surgery.
Final Report:

Crash of a Piper PA-46-500TP Malibu Meridian in Three Hills

Date & Time: Jan 29, 2013 at 0915 LT
Registration:
C-GMHP
Flight Type:
Survivors:
Yes
Schedule:
La Crete - Three Hills
MSN:
46-97332
YOM:
2008
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Three Hills Airport, the pilot encountered poor weather conditions. Too low, the single engine airplane struck the ground, lost its left wing and came to rest in a snow covered field. All three occupants were rescued, among them a passenger was slightly injured. The aircraft was damaged beyond repair.

Crash of a Britten Norman BN-2B-26 Islander at Okiwi Station

Date & Time: Jan 25, 2013 at 0827 LT
Type of aircraft:
Operator:
Registration:
ZK-DLA
Survivors:
Yes
Schedule:
Auckland – Okiwi Station
MSN:
2131
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3170
Captain / Total hours on type:
296.00
Circumstances:
On approach to runway 18 at Okiwi, New Zealand, the aircraft encountered windshear on short final as the pilot reduced power to land. The pilot was unable to arrest the descent rate and the aircraft landed heavily. Damage was caused to both landing gear oleos and one brake unit, with rippling found on the upper and lower skin of each wing. One passenger sustained a back injury, which was later identified as a fractured vertebra. The pilot was aware of fluctuating wind conditions at Okiwi and had increased the approach speed to 70 knots as per company standard operating procedures. The pilot reported that despite this, the airspeed reduced rapidly and significantly at 10 to 15 feet agl, leaving little time to react to the situation.
Probable cause:
Loss of height and hard landing due to windshear on short final.

Crash of a Casa 212 Aviocar 300 in Bloemfontein

Date & Time: Jan 17, 2013 at 1030 LT
Type of aircraft:
Operator:
Registration:
8020
Survivors:
Yes
Schedule:
Bloemfontein - Bloemfontein
MSN:
371
YOM:
1988
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was engaged in a local paratroopers/skydiving mission at Bloemspruit AFB that shares a runway with Bloemfontein-Bram Fischer International Airport. For unknown reasons, the aircraft landed hard on its nose, veered off runway and came to rest with its left wing on the ground. All five crew members escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Hermosillo

Date & Time: Jan 13, 2013 at 1800 LT
Registration:
N6081Y
Flight Type:
Survivors:
Yes
MSN:
61-0681-7963321
YOM:
1979
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft suffered an accident at Hermosillo-General Ignacio Pesqueira Garcia Airport. After touchdown, the airplane veered off runway, collided with a fence and came to rest on its belly. All occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-60 Aerostar (Ted Smith 602P) in North Las Vegas

Date & Time: Jan 2, 2013 at 1515 LT
Registration:
N3AG
Flight Type:
Survivors:
Yes
Schedule:
North Las Vegas - North Las Vegas
MSN:
60-8365-018
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3900
Captain / Total hours on type:
1700.00
Copilot / Total flying hours:
11535
Copilot / Total hours on type:
60
Aircraft flight hours:
3259
Circumstances:
The pilot receiving instruction conducted three full-stop landings without incident. After the fourth takeoff, the flight instructor simulated a prearranged left engine failure about 600 ft above ground level (agl). The pilot followed emergency procedures, used the checklist, and prepared to land. The pilot reported that, when the airplane was about 50 to 100 ft agl on final approach, he thought that it was a little too high, so he chose to initiate a go-around. He moved the throttle levers full forward, but neither engine responded. The flight instructor pushed the airplane's nose down, and the pilot continued the approach. On touchdown, the right main and nose landing gear collapsed. A postimpact fire ensued, which consumed most of the airplane. Postaccident examination of the landing gear revealed that it collapsed due to bending overload consistent with a hard landing. The reason for the failure of both engines to respond to power inputs could not be determined because of the postcrash fire damage.
Probable cause:
The pilot's failure to maintain an adequate descent rate while on final approach, which resulted in a hard landing and landing gear collapse due to overload following the failure of both engines to respond to power inputs during an attempted go-around for reasons that could not be determined due to postcrash fire damage.
Final Report: