Crash of an ATR42-320 in Jersey

Date & Time: Jun 16, 2012 at 0823 LT
Type of aircraft:
Operator:
Registration:
G-DRFC
Survivors:
Yes
Schedule:
Guernsey - Jersey
MSN:
007
YOM:
1986
Flight number:
BCI308
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6106
Captain / Total hours on type:
1255.00
Circumstances:
The crew, comprising a commander, co-pilot and cabin crewmember, reported for duty at 0620 hrs at Guernsey Airport. The commander was conducting line training of the co-pilot, a first officer who had recently joined the companyThe first sector was to be from Guernsey to Jersey. No problems were identified during the pre-flight preparation and the aircraft departed on time at 0705 hrs, with the commander acting as handling pilot. The short flight was without incident and the weather for landing was reported as good, with the wind from 210° at 16 kt, FEW cloud at 2,000 ft and visibility in excess of 10 km. The commander elected to carry out a visual approach to Runway 27 at Jersey, using a planned approach speed of 107 kt and flap 30 selected for landing. During the approach, the gear was selected down and the flight crew confirmed the three green ‘gear safe’ indication lights were illuminated, indicating that the gear was locked in the down position. The commander reported that both the approach and touchdown seemed normal, with the crosswind from the left resulting in the left main gear touching first. Just after touchdown both pilots heard a noise and the commander stated the aircraft appeared to settle slightly differently from usual. This made him believe that a tyre had burst. The cabin crew member also heard a noise after touchdown which she too thought was from a tyre bursting. The commander selected ground idle and partial reverse pitch and, as the aircraft decelerated through 70 kt, the co-pilot took over control of the ailerons, as per standard procedures, to allow the commander to take control of the steering tiller. The co-pilot reported that despite applying corrective inputs the aircraft continued rolling to the left. A member of ground operations staff, situated at Holding Point E, reported to the tower controller that the left landing gear leg of the aircraft did not appear to be down properly as it passed him. The aircraft continued to quickly roll to the left until the left wingtip and propeller contacted the runway. The aircraft remained on the runway, rapidly coming to a halt to the left of the centreline, approximately abeam Holding Point D. Both propellers continued to rotate and the commander selected the condition levers to the fuel shutoff position and pulled the fire handles to shut both engines down. The tower controller, seeing the incident, pressed the crash alarm and airfield emergency services were quickly in attendance.
Probable cause:
The recorded data indicates that the rate of descent during the final approach phase was not excessive and remained low through the period of the touchdown. Although the registered vertical acceleration at ground contact was high, this is not consistent with the recorded descent rate and is believed to have been the effect of the close physical proximity of the accelerometer to the location of the fractured side brace. It is reasonable to assume that the release of strain energy during the fracturing process produced an instant shock load recorded as a 3 g spike.The general nature of the failure mechanism precipitating the collapse of the landing gear is clear. A fatigue crack propagated through most of the cross-section of one side of an attachment lug of the left main landing gear side brace upper arm. This continued as a final region of ductile cracking until complete failure occurred. The increased loading, during normal operation, on other elements of the twin lugs, once the initial crack was large or had passed completely through the section, led to overloading in the other section of the forward lug and both sections of the aft lug. This caused rapid onset of three small areas of fatigue damage followed by ductile overload failure of both lugs. The failure rendered the side brace ineffective and the unrestrained main trunnion continued to translate outboard leading to the collapse of the gear. The aluminium was found to be within the specifications to which it was made. The initial fatigue crack emanated from a feature which was inter-granular and high in titanium content, which was probably a TiB2 particle introduced during grain refining. This was surrounded by an area consistent with static loading before propagating a crack in fatigue. Given that there was not a measurable effect on the fatigue life of the material with the feature, and that an area of static overload was evident immediately surrounding the TiB2 particle, it is therefore concluded that at some time during the life of the side brace component it probably suffered a single loading event sufficient to exploit the presence of the origin, initiating a crack that remained undetectable until failure.
Final Report:

Crash of a Let L-410UVP in Borodyanka: 5 killed

Date & Time: Jun 10, 2012 at 1040 LT
Type of aircraft:
Registration:
UR-SKD
Survivors:
Yes
Schedule:
Borodyanka - Borodyanka
MSN:
81 07 21
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Owned by Skaidens (Skydance), the twin engine aircraft was engaged on local skydiving mission and operated on behalf of the Ukrainska Shkola Pilotov (Ukrainian Pilots' School). On board were 20 skydivers and two pilots. After take off from Borodyanka Aerodrome, the crew realized that weather conditions deteriorated and that a thunderstorm was approaching the airfield. The crew decided to cancel the mission and to return to the airport. On final approach, the aircraft encountered downdrafts and microburst. It lost height and crashed in a field some 900 meters short of runway threshold. Five skydivers were killed while 17 other occupants were injured, some seriously.
Probable cause:
According to the findings of the commission of inquiry, the most likely cause of the crash was the impact of the aircraft in a low-altitude wind due to strong downward air flow (micro-burst) during the landing of the aircraft in thunderstorms due to coincidence of the following negative factors.
- Failure of the crew to perform a go around or divert to the alternate aerodrome;
- A rapid increase in the speed of movement of the thunderstorm in the direction of the Borodyanka airfield area;
- Lack of training on the simulator in the conditions of wind shear, lack of experience in the crew on approach to landing in the conditions of wind shear, in particular micro-burst;
- Insufficient aeronautical equipment (lack of meteorological radar on the plane and airfield);
- Lack of information for the crew about the forecasted and actual meteorological conditions at the landing aerodrome, warnings about the forecasted / available wind shift at Borodyanka aerodrome;
- The crew was not sufficiently informed about the flight conditions due to insufficient lighting of the cockpit and failure of the instrumentation of the aircraft due to a power failure during approach in thunderstorm conditions;
- Lack of sufficient experience of the crew to perform activities and landings in conditions when the landing weight exceeded the maximum allowable, due to the presence of skydivers on board the aircraft;
- Motivation of the crew to perform the landing approach on the first attempt, due to insufficient information about the storm at the aerodrome. The information on wind increase and its direction (provided to the pilot) was perceived by the crew as possible conditions for landing because their parameters did not exceed the limits allowed by the AOM of the aircraft;
- Overloading of the aircraft, motivation of the decision of the captain to perform landing at the aerodrome of departure (Borodyanka) due to the presence of unregistered passengers on board, due to improper organization of boarding of skydivers at the aerodrome Borodyanka;
- Insufficient organization of flights at Borodyanka airfield in terms of meteorological support;
- Insufficient (weak) regulatory, regulatory, legislative framework for parachuting.

Crash of a Learjet 60 in Aspen

Date & Time: Jun 7, 2012 at 1224 LT
Type of aircraft:
Registration:
N500SW
Flight Type:
Survivors:
Yes
Schedule:
Miami-Opa Locka - Aspen
MSN:
60-017
YOM:
1993
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18000
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
13500
Aircraft flight hours:
6456
Circumstances:
While the first officer was flying the airplane on a visual approach to the airport located in a steep mountain valley, the tower controller informed him that the pilot of a Citation that had landed about 10 minutes earlier had reported low-level windshear with a 15-knot loss of airspeed on short final. The first officer used the spoilers while on the left base leg and then maneuvered the airplane in an "S-turn" on the final leg to correct for a too-steep approach. Just as the airplane was about to touch down with the airspeed decreasing, the captain made several calls for "power" and then called for a "go around." However, the first officer did not add power for a go-around, and the captain did not take control of the airplane. Both pilots reported that, when the airplane was about 30 ft above ground level (agl), they felt a sensation that the airplane had "stopped flying" with a simultaneous left roll, which is indicative of an aerodynamic stall, followed by an immediate impact with terrain. After striking obstructions that completely separated the right main landing gear and the right flap, the airplane came to rest upright in the dirt on the side of the runway about 4,000 ft from the initial impact point. The airplane sustained substantial damage to the fuselage and both wings. All eight occupants evacuated through the main cabin door. There was a substantial fuel spill but no postimpact fire. Both pilots reported no mechanical malfunctions or failures of the airplane, and neither pilot reported an uncommanded loss of engine power. Data from the enhanced ground proximity warning system showed that seven warning events occurred in the last 3 minutes before the accident. The first warning was for "sink rate," and it occurred when the airplane was about 1,317 ft agl and in a 3,400-ft-per-minute descent. The last warning was for "bank angle," and it occurred about 10 seconds before touchdown as the airplane exceeded 42 degrees of bank when it was about 200 ft agl. The wind recorded at the airport at the time of the accident would have resulted in a 12-knot variable tailwind with gusts to 18 knots. The evidence is consistent with the first officer flying a non stabilized approach with a decreasing airspeed during low-level windshear conditions. The first officer did not properly compensate for the known low-level windshear conditions and allowed the airspeed to continue to decrease and the bank angle to increase until the airplane experienced an aerodynamic stall.
Probable cause:
The first officer's failure to maintain adequate airspeed and his exceedance of the airplane's critical angle-of-attack during the final approach in known low-level windshear conditions, which resulted in an aerodynamic stall. Contributing to the accident were the first officer's failure to initiate a go-around when commanded and the captain's lack of remedial action when he recognized that the approach was unstabilized.
Final Report:

Crash of a McDonnell Douglas MD-83 in Lagos: 159 killed

Date & Time: Jun 3, 2012 at 1545 LT
Type of aircraft:
Operator:
Registration:
5N-RAM
Survivors:
No
Site:
Schedule:
Abuja - Lagos
MSN:
53019/1783
YOM:
1990
Flight number:
DAV992
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
147
Pax fatalities:
Other fatalities:
Total fatalities:
159
Captain / Total flying hours:
18116
Captain / Total hours on type:
7466.00
Copilot / Total flying hours:
1143
Copilot / Total hours on type:
808
Aircraft flight hours:
60850
Aircraft flight cycles:
35220
Circumstances:
On 3rd June, 2012 at about 1545:00hrs, 5N-RAM, a Boeing MD-83, a domestic scheduled commercial flight, operated by Dana Airlines (Nig.) Limited as flight 0992 (DANACO 0992), crashed into a densely populated area of Iju-Ishaga, a suburb of Lagos, following engine number 1 loss of power seventeen minutes into the flight and engine number 2 loss of power while on final approach to Murtala Muhammed Airport Lagos, Nigeria. Visual Meteorological Conditions prevailed at the time and the airplane was on an instrument flight plan. All 153 persons onboard the airplane, including the six crew were fatally injured. There were also six confirmed ground fatalities. The airplane was destroyed. There was post impact fire. The flight originated at Abuja (ABV) and the destination was Lagos (LOS). The airplane was on the fourth flight segment of the day, consisting of two round-trips between Lagos and Abuja. The accident occurred during the return leg of the second trip. DANACO 0992 was on final approach to runway 18R at LOS when the crew declared a Mayday call “Dual Engine Failure – negative response from the throttles.” According to records, the flight arrived ABV as Dana Air flight 0993 at about 1350:00hrs and routine turn-around activities were carried out. DANACO 0992 initiated engine start up at 1436:00hrs. Abuja Control Tower cleared the aircraft to taxi to the holding point of runway 04. En-route ATC clearance was passed on to DANACO 0992 on approaching holding point of runway 04. According to the ATC ground recorder transcript, the aircraft was cleared to line-up on runway 04 and wait, but the crew requested for some time before lining-up. DANACO 0992 was airborne at 1458:00hrs after reporting a fuel endurance of 3 hours 30 minutes. The aircraft made contact with Lagos Area Control Centre at 1518:00hrs and reported 1545:00hrs as the estimated time of arrival at LOS at cruising altitude of 26,000 ft. The Cockpit Voice Recorder (CVR) retained about 30 minutes 53 seconds of the flight and started recording at 1513:44hrs by which time the Captain and First Officer (F/O) were in a discussion of a non-normal condition regarding the correlation between the engine throttle setting and an engine power indication. However, they did not voice concerns then that the condition would affect the continuation of the flight. The flight crew continued to monitor the condition and became increasingly concerned as the flight transitioned through the initial descent from cruise altitude at 1522:00hrs and the subsequent approach phase. DANACO 0992 reported passing 18,100ft and 7,700ft, at 1530:00hrs and 1540:00hrs respectively. After receiving radar vectors in heading and altitude from the Controller, the aircraft was issued the final heading to intercept the final approach course for runway 18R. According to CVR transcript, at 1527:30hrs the F/O advised the Captain to use runway 18R for landing and the request was made at 1531:49hrs and subsequently approved by the Radar Controller. The crew accordingly changed the decision height to correspond with runway 18R. At 1531:12hrs, the crew confirmed that there was no throttle response on the left engine and subsequently the Captain took over control as Pilot Flying (PF) at 1531:27hrs. The flight was however continued towards Lagos with no declaration of any distress message. With the confirmation of throttle response on the right engine, the engine anti-ice, ignition and bleed-air were all switched off. At 1532:05hrs, the crew observed the loss of thrust in No.1 Engine of the aircraft. During the period between 1537:00hrs and 1541:00hrs, the flight crew engaged in prelanding tasks including deployment of the slats, and extension of the flaps and landing gears. At 1541:46hrs the First Officer inquired, "both engines coming up?" and the Captain replied “negative” at 1541:48hrs. The flight crew subsequently discussed and agreed to declare an emergency. At 1542:10hrs, DANACO 0992 radioed an emergency distress call indicating "dual engine failure . . . negative response from throttle." At 1542:35hrs, the flight crew lowered the flaps further and continued with the approach and discussed landing alternatively on runway 18L. At 1542:45hrs, the Captain reported the runway in sight and instructed the F/O to retract the flaps and four seconds later to retract the landing gears. At 1543:27hrs, the Captain informed the F/O, "we just lost everything, we lost an engine. I lost both engines". During the next 25 seconds until the end of the CVR recording, the flight crew attempted to recover engine power without reference to any Checklist. The airplane crashed into a densely populated residential area about 5.8 miles north of LOS. The airplane wreckage was approximately on the extended centreline of runway 18R, with the main wreckage concentrated at N 06o 40.310’ E 003o 18.837' coordinates, with elevation of 177ft. During the impact sequence, the airplane struck an uncompleted building, two trees and three other buildings. The wreckage was confined in a small area, with the separated tail section and engines located at the beginning of the debris trail. The airplane was mostly consumed by post crash fire. The tail section, both engines and portions of both wings representing only about 15% of the airplane, were recovered from the accident site for further examination.
Probable cause:
Probable Causal Factors:
1. Engine number 1 lost power seventeen minutes into the flight, and thereafter on final approach, Engine number 2 lost power and failed to respond to throttle movement on demand for increased power to sustain the aircraft in its flight configuration.
2. The inappropriate omission of the use of the Checklist, and the crew’s inability to appreciate the severity of the power-related problem, and their subsequent failure to land at the nearest suitable airfield.
3. Lack of situation awareness, inappropriate decision making, and poor airmanship.

Tear down of the engines showed that the no.1 engine was overhauled in the U.S in August 2011 and was not in compliance with Service Bulletin SB 6452. Both engines had primary and secondary fuel manifold assemblies fractured, cracked, bent, twisted or pinched which led to fuel leaks, fuel discharge to bypass duct, loss of engine thrust and obvious failure of engine responding to
throttle movement. This condition was similar to the no.1 engine of a different Dana Air MD-80, 5N-SAI, that was involved in an incident in October 2013 when the aircraft returned to the departure airport with the engine not responding th throttle movements. This engine also was not in compliance with Service Bulletin SB 6452. This bulletin was issued in 2003 and called for the installation of new secondary fuel manifold assemblies, incorporating tubes fabricated from new material which has a fatigue life that was approximately 2 times greater than the previous tube material.
Final Report:

Crash of a Boeing 727-221F in Accra: 10 killed

Date & Time: Jun 2, 2012 at 1910 LT
Type of aircraft:
Operator:
Registration:
5N-BJN
Flight Type:
Survivors:
Yes
Schedule:
Lagos - Accra
MSN:
22540/1796
YOM:
1982
Flight number:
DHC111
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
14000
Captain / Total hours on type:
1464.00
Copilot / Total flying hours:
22463
Copilot / Total hours on type:
4180
Aircraft flight hours:
40251
Aircraft flight cycles:
25380
Circumstances:
On 2nd June, 2012 at 1828hrs Allied Air Ltd Flight DHV 111, a Boeing 727-221 Cargo aircraft, Registration: 5N-BJN, departed Murtala Muhammed International Airport, Ikeja, Lagos-Nigeria to Kotoka International Airport, estimating Accra, Ghana at 1904hrs, en-route to Abidjan. While taxiing for take-off, the Flight Engineer observed that the CSD amber light (caution) had illuminated on the panel. With the Captain’s permission, it was disconnected. The flight was cleared Flight Level 240 and to maintain by Accra Area Control on 130.9MHz. The Flight was operating under Instrument Flight Rules (IFR) conditions and the flight was turbulent, the aircraft was cruising at a speed of 280kts which is the recommended turbulence speed. On the descent into Accra, the aircraft was cleared by Accra Approach on 119.5MHz initially to Flight Level 50 and later cleared to 2000ft. It was again instructed to climb to 3000ft due to high ground. On arrival at Accra, the Captain flew an Instrument Landing System (ILS) coupled approach, until he saw the runway. He then disconnected the autopilot at 500ft and manually flew the aircraft. After disconnecting the auto-pilot, he came into heavy IMC conditions in rain. The aircraft experienced an unstable approach at a high speed of 167kts and landed with a wind of 050/15kts at 154 kts and about 5807 ft from Runway 21 in nil visibility. The crew deployed thrust reversers and applied the normal brakes as well as the emergency pneumatic brakes but these actions were ineffective to stop the aircraft. Normally deploying the thrust reversers or applying the brakes would bring the nose wheel down. However, the nose gear was kept up. The speed brakes were not deployed. The crew reported seeing red lights rushing towards them soon after the main wheels touched the ground for the landing run. The aircraft nose gear never touched the ground until the aircraft went over the fence wall. A Lufthansa Flight DLH 566 operated on behalf of Lufthansa (LH) by Private Air which had landed earlier at 1902hrs reported a wind of 050/15kts and visibility of 3800m in rain. From the 2nd intersection where DLH 566 had stopped, ready to backtrack Runway 21, the crew observed Allied Air appeared to have landed at very high speed when the aircraft went past and could not determine whether the aircraft was taking off. A Lufthansa ground engineer who was waiting at the intersection to receive DLH 566 indicated the approximate touchdown point of DHV 111. Both the controller at the Tower and the Marshaller in the “follow me” vehicle waiting at the 1st Intersection saw Allied Air land between the 1st and 2nd intersections. The FDR indicated that the aircraft landed 4000 ft to the end of Runway 21. The full length of Runway 21 is 3403 m (11,162ft for take-off) but available for landing is 2990 m (9,807 ft). The FDR readout showed that the aircraft landed at 150 kts, and at 1.6 G, 5807 ft from the beginning of Runway 21 and 4000ft from the threshold of the Runway 03. The runway surface condition for braking as described by DLH crew was good. Shortly after Turkish Airline (THY 629) had landed, DLH 566 also landed followed by DHV 111. The aircraft over-run the runway and destroyed the Threshold Lights and the Approach lights on Runway 03. It knocked out the ILS Localizer transmitter structure and mounts, broke through the airport perimeter wall. The aircraft crossed Giffard Road, collided with a passenger mini bus killing all ten (10) persons on board. It uprooted a tree by the road side before finally coming to a stop at an open space near El-Wak Sport Stadium. The Emergency Locator Transmitter (ELT) was triggered by the impact. The right side of a taxi cab on the road was grazed by flying debris from the localizer transmitter structures carried along by the right wing of the aircraft. The leading edge of the wing was extensively damaged. The aircraft came to a rest outside the airport perimeter wall 1171 ft (350m) from the Threshold of Runway 03, heading 215° southwest, coordinates 05 35 13.67N 000o 10 29.20W. The four (4) crew members sustained minor injuries. The aircraft and the mini bus were all destroyed. At 1910hrs, RFFS was alerted by the Tower Controller through the crash alarm bell. It took 9 minutes for the firemen to get to the crash site. The Airport was closed for 45minutes during which runway inspection was carried out. No pool of water was found anywhere on the runway. Approximately one hour after the aircraft had over-run the runway, the Airport was re-opened to traffic. Other airlines including KLM and British Airways, landed. Even though the Technical Log Book had no records of deferred defect, the Captain in an interview said the windshield wipers where switched on during the landing phase but were unable to clear the rain. It was observed during the investigation that the windshield wipers were rather ¾ switched on.
Probable cause:
The probable causes of the accident were:
The decision of the Captain to continue with the landing instead of aborting at the missed approach point especially when he could hardly see through the windshield and when he did not know how far he had gone down the runway because of the rain and the tail wind components.
Contributory factors:
a. The Captain disconnected the auto-pilot and flew the aircraft manually in an unstable approach.
b. The Captain landed the aircraft at 4000ft to the threshold of Runway 03, 6060ft from Runway 21. He could not stop within the available distance.
c. The Captain chose to land with a tailwind of 050/15Kts in excess of maximum allowable tailwind of 10Kts.
d. The crew concentrated on tracking the Localizer rather than watching for threshold and runway edge lights. They suffered from fixation.
e. The Captain did not deploy speed brakes on landing.
Final Report:

Crash of a Boeing 737-4Y0 in Pontianak

Date & Time: Jun 1, 2012 at 1235 LT
Type of aircraft:
Operator:
Registration:
PK-CJV
Survivors:
Yes
Schedule:
Jakarta - Pontianak
MSN:
24689/1883
YOM:
1990
Flight number:
SJY188
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Circumstances:
The approach to Pontianak was unstable and really difficult due to turbulence and poor weather conditions (heavy rain falls). The aircraft landed on wet runway 15 and skidded. It eventually veered off runway to the left and went through a muddy field. The nose gear was torn off while both main gears sank, leaving both engines on the ground. While all 163 occupants were evacuated safely, the aircraft was damaged beyond repair. At the time of the accident, weather conditions were as follow: wind from 230 at 22 knots, visibility 600 metres, few clouds at 900 feet, broken at 700 feet, CB's above the terrain and turbulences.

Crash of a Cessna 208B Grand Caravan in Lézignan-Corbières

Date & Time: May 25, 2012 at 1710 LT
Type of aircraft:
Operator:
Registration:
D-FAAF
Survivors:
Yes
Schedule:
Lézignan-Corbières - Lézignan-Corbières
MSN:
208B-1125
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1900
Captain / Total hours on type:
850.00
Circumstances:
The single engine aircraft departed Lézignan-Corbières Airport at 1650LT with a pilot and several skydivers on board. At 10,500 feet, all skydivers jumped out and the pilot reduced his altitude to return to his base. On final approach to runway 08, at a height of 700 feet and at a speed of 90 knots, the pilot slightly increased the engine power to maintain the glide and then reduced again the power. At this time, the engine stopped and the propeller auto-feathered. Unable to reach the runway, the pilot attempted an emergency landing in a vineyard located some 800 meters short of runway 08, to the right of its extended centerline. While the pilot was uninjured, the aircraft was damaged beyond repair.
Probable cause:
Investigation were unable to determine the cause of the turbine failure on final approach. Sufficient fuel (about 500 pounds) was still present in the tanks and all analysis of the engine, fuel supply control system and the fuel pump did not reveal any anomalies.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Lillabelle Lake: 2 killed

Date & Time: May 25, 2012 at 1408 LT
Type of aircraft:
Operator:
Registration:
C-FGBF
Survivors:
Yes
Schedule:
Edgar Lake - Lillabelle Lake
MSN:
168
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1100
Captain / Total hours on type:
300.00
Aircraft flight hours:
22000
Circumstances:
The Cochrane Air Service de Havilland DHC-2 Mk.1 Beaver floatplane (registration C-FGBF, serial number 168) departed Edgar Lake, Ontario, with 2 passengers and 300 pounds of cargo on board. The aircraft was destined for the company’s main base located on Lillabelle Lake, Ontario, approximately 77 miles to the south. On arrival, a southwest-bound landing was attempted across the narrow width of the lake, as the winds favoured this direction. The pilot was unable to land the aircraft in the distance available and executed a go-around. At 1408, Eastern Daylight Time, shortly after full power application, the aircraft rolled quickly to the left and struck the water in a partially inverted attitude. The aircraft came to rest on the muddy lake bottom, partially suspended by the undamaged floats. The passenger in the front seat was able to exit the aircraft and was subsequently rescued. The pilot and rear-seat passenger were not able to exit and drowned. The emergency locator transmitter activated on impact.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On the windward side of the landing surface, there was significant mechanical turbulence and associated wind shear caused by the passage of strong gusty winds over surface obstructions.
2. During the attempted overshoot, the rapid application of full power caused the aircraft to yaw to the left, and a left roll quickly developed. This movement, in combination with a high angle of attack and low airspeed, likely caused the aircraft to stall. The altitude available to regain control before striking the water was insufficient.
3. The pilot survived the impact, but was unable to exit the aircraft, possibly due to difficulties finding or opening an exit. The pilot subsequently drowned.
4. The rear-seat passenger did not have a shoulder harness and was critically injured. The passenger’s head struck the pilot’s seat in front; this passenger did not exit the aircraft and drowned.
Findings as to Risk:
1. Without a full passenger safety briefing, there is increased risk that passengers may not use the available safety equipment or be able to perform necessary emergency functions in a timely manner to avoid injury or death.
2. Not wearing a shoulder harness can increase the risk of injury or death in an accident.
3. Not having a stall warning system increases the risk that the pilot may not be aware of an impending aerodynamic stall.
4. Commercial seaplane pilots who do not receive underwater egress training are at increased risk of being unable to exit the aircraft following a survivable impact with water.
Final Report:

Crash of an Antonov AN-30B at Čáslav AFB

Date & Time: May 23, 2012 at 1150 LT
Type of aircraft:
Operator:
Registration:
04 black
Flight Type:
Survivors:
Yes
Schedule:
Čáslav - Čáslav
MSN:
0704
YOM:
1975
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was engaged in a training exercise at Čáslav AFB, carrying 14 Russian soldiers and 9 Czech soldiers. Upon landing in a nose-down attitude, the aircraft bounced twice. The nose gear collapsed and the aircraft skidded on runway. Unable to stop within the remaining distance, the aircraft overran and came to rest in an open field, broken in two and bursting into flames. Seven occupants were injured, among them two seriously. The aircraft was partially destroyed by fire.
Probable cause:
Wrong approach configuration on part of the crew who completed the landing at an excessive speed of 260 km/h and in a nose-down attitude, causing the nose gear to collapse due g-load estimated between 1.6 and 3.3 g.

Crash of a Dornier DO228-212 in Jomsom: 15 killed

Date & Time: May 14, 2012 at 0945 LT
Type of aircraft:
Operator:
Registration:
9N-AIG
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
8216
YOM:
1997
Flight number:
AG-CHT
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
5776
Captain / Total hours on type:
596.00
Circumstances:
On final approach to Jomsom Airport runway 06, the crew lowered the landing gear when they noticed a technical issue. On short final, the captain decided to initiate a go-around procedure and to divert to Pokhara. He made a sharp U-turn to the left at a speed of 73 knots when the left wing impacted a rocky hill located 270 meters above the runway 24 threshold. The aircraft stalled and crashed on the slope of the hill and was destroyed by impact forces. The stewardess and five passengers were seriously injured while all 15 other occupants, among them both pilots, were killed.
Probable cause:
The captain took the decision to make a sharp turn to the left at 73 knots without considering the turn radial and the rising terrain, which resulted in a continuous stall warning during the remaining 12 seconds of flight. The left hand wing of the aircraft struck a rock and the aircraft crashed. The decision of the captain to initiate a turn to the left at this stage of the flight was against all published procedures. It was reported that the commander was a senior flight instructor employed by the Civil Aviation Authority of Nepal.