Landing (descent or approach)

Flight Type:

Private

Survivors:

Site:

Schedule:

Maribo – Cuers

MSN:

157

YOM:

1999

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

8000

Captain / Total hours on type:

6000.00

Circumstances:

The pilot took off at around 14 h 45 from Maribo aerodrome (Denmark) bound for Cuers. He filed an IFR flight plan that he cancelled(2) at 17 h 15 near the St Tropez VOR (83). He explained that he had overflown the installations at Cuers at 1,500 ft and started an aerodrome circuit via the north for runway 11. He was visual with the ground and noted the presence of snow showers. He reckoned that these conditions made it possible to continue the approach. At about 600 ft, he went into a snow shower. At about 400 ft, he noticed that the horizontal visibility was zero and that he had lost all external visual references. He tried to make a go-around but didn’t feel any increase in engine power. At about 200 ft, he saw that he was to the right of the runway and decided to make an emergency landing. The aeroplane struck the ground on the right side of the runway. It slid for 150 metres and swung around before stopping. All three occupants escaped with minor injuries and the aircraft was damaged beyond repair.

Probable cause:

The accident was linked to the pilot’s to continue his approach under VFR, even though the meteorological conditions made it impossible. Coming out of an area of thick snowfall at 200 ft, he was unable to control the bank angle or the flight path of the aeroplane. The investigation was unable to determine if this bank angle was linked to inadequate control during an attempt to go around without external visual references(3) or a late attempt to reach the centre of the runway. Overconfidence in his abilities to pass through a snow shower, as well as a determination to land, may have contributed to the accident.

Final Report:

Crash of a Cessna 402B off Punto Fijo

Date & Time: Feb 9, 2012 at 1200 LT

Type of aircraft:

Cessna 402

Operator:

Registration:

YV2663

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Valera - Punto Fijo

MSN:

402B-1024

YOM:

1975

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft was performing a cargo flight from Valera-Dr. Antonio Nicolás Briceño Airport to Punto Fijo, carrying one passenger, two pilots and a load consisting of valuables. On approach to Punto Fijo-Josefa Camejo Airport, the crew encountered technical problems and ditched the aircraft off the Amuay refinery. The aircraft sank in shallow water and all three occupants took refuge on the roof of the airplane before being rescued few minutes later.

Probable cause:

The failure of the seal of the balance tube on the left engine intake manifold, causing a loss of manifold pressure and then a loss of engine power.
Contributing Factor:
- Discrepancies found with the quality control of the maintenance services performed on the aircraft,
- The non-assertive decisions taken during the flight when the emergency occurred.

Crash of a Beechcraft F90 King Air off Belém

Date & Time: Feb 8, 2012 at 2244 LT

Type of aircraft:

Beechcraft 90 King Air

Operator:

Registration:

PT-OFD

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Belém-Val de Cans-Júlio Cezar Ribeiro

Site:

Lake, Sea, Ocean, River

Schedule:

São Paulo – Belém

MSN:

LA-118

YOM:

1981

Location:

Pará

Country:

Brazil

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5500

Captain / Total hours on type:

70.00

Copilot / Total flying hours:

6750

Copilot / Total hours on type:

Circumstances:

The aircraft departed São Paulo-Congonhas Airport at 1630LT on a flight to Belém, carrying two passengers and two pilots. During the approach to Belém-Val de Cans-Júlio Cezar Ribeiro Airport runway 06 by night, one of the engine flamed out. Few seconds later, the second engine failed as well. The crew ditched the aircraft in the Bay of Guajará, about 1,2 km short of runway 06 threshold. All four occupants were rescued by servicemen of the Naval Base who were on duty at the time of the accident. A pilot was slightly injured while three other occupants escaped uninjured. The aircraft sank and the wreckage was recovered 12 days later.

Probable cause:

The following findings were identified:
a) The pilots had valid aeronautical medical certificates;
b) The pilots had valid technical qualification certificates;
c) The aircraft captain had qualification and enough experience for the flight in question;
d) The copilot was under training;
e) The aircraft had a valid airworthiness certificate;
f) The planning of the flight from SBSP to SBBE was done by the pilot in command, who took in consideration an aircraft with a full load of fuel;
g) The flight plan read that the fuel endurance was 7 hours and 30 minutes of flight, for an estimated elapse time of 5 hours and 40 minutes at FL230;
h) When the aircraft was passing over the city of Palmas, State of Tocantins, the pilots decided, in conjunction, to proceed non-stop to the destination, discarding the need to make an intermediate landing for refueling;
i) The aircraft was registered in the passenger transport category (TPP) and was engaged in the transport of a sick person;
j) The fuel quantity indicators and the fuel flow indicators of the aircraft were not showing dependable information;
k) The flight plan for the leg betwren SBSP and SBBE contained information of sick person transportation, but there was no sick person on board;
l) The aircraft made a ditching near the banks of Guajará Bay, at a distance of approximately 1,200 meters from the threshold of runway 06 of SBBE;
m) The passengers and crew were rescued by Brazilian Navy servicemen on duty on the Naval Base of Val de Cans;
n) One of the pilots and both passengers got out uninjured, while the other pilot suffered minor injuries; and
o) The aircraft sustained substantial damage.
Contributing factors:
Concerning the operation of the aircraft
a) Attitude – a contributor
The captain failed to comply with norms and procedures by accepting to fly an aircraft on his day of rest, even knowing that he was to start his on-call duty hours as soon as he landed in SBBE.
He also showed to be overconfident when he decided to fly directly from SBSP to SBBE, trusting the 7-hour fuel endurance of his aircraft and the fuel consumption information displayed by the instruments, even after identifying their malfunction. The pilot under training, in turn, was complacent by accepting and agreeing with the pilot-in-command’s decision, without questioning his calculations or motivations for flying direct to the destination.
b) Motivation – a contributor
The captain was eager to return to SBBE on that same day, because he was supposed to start his on-call duty hours in the air taxi company for which he worked.
c) Decision-making process – a contributor
The captain failed to comply with important aspects concerning the route conditions and aircraft instruments by making a decision to fly directly from SBSP to SBBE.
Psychosocial information
a) Communication – a contributor
There was lack of assertiveness on the part of the copilot since he did not question the captain’s calculations and/or motivations to fly non-stop, when he (the copilot) considered that making a stop for refueling would be safer.
b) External influence – a contributor
The involvement of the captain with activities of another company on that same day, in addition to events belonging to his private life, had influence on his decisions in the initial planning of the flight and during the flight en route.
Organizational information
a) Work organization – a contributor
The company delegated responsibility for the entire planning of the flight to the pilots. Therefore, there was not any interference on the part of the company in the crew’s work day and in the legs defined for the flight.
b) Organizational culture – a contributor
The fact that the company performed an operation for which it was not certified reflected the fragility of an organizational culture which allowed it to perform activities unfavorable to operational safety.
Operational Factor
Concerning the operation of the aircraft
a) Flight indiscipline – a contributor
On several occasions during the flight, the pilots failed to comply with the norms and regulations in force, such as the sections 91.167 and 91.205 of the RBHA 91, the Pilot Operating Handbook and FAA Approved Airplane Flight Manual, and the Lei do Aeronauta (Law of the Aeronaut, Law nº 7.183 of 5 April 1984).
b) Training – undetermined
Before the ditching, the pilot unlocked the rear door of the aircraft and, then, failed to instruct the passengers as to the opening of the emergency exit. This fact shows a probable deviation in the process of training previously received by the captain, since the procedure prescribed for the situation was to abandon the aircraft through the emergency exit, which had to be unlocked after the ditching.
c) Piloting judgment – a contributor
At the moment of their decision to proceed non-stop to the destination, there was an inappropriate evaluation on the part of the crew, because they did not consider the hourly consumption until that point, and the malfunction of the fuel capacity indicator did not allow them to know the exact amount of fuel remaining in the tanks.
d) Flight planning – a contributor
There was a mistake on the part of the captain relative to the planning of the flight, since, in addition to a total flight time of 5 hours and 40 minutes, he did not consider the fuel necessary to fly to an alternate airport plus 45 minutes of flight. The captain and the pilot under training made an inappropriate evaluation of the effects brought by the operational conditions along the flight route.

Final Report:

Crash of a PZL-Mielec AN-28 in Namoya: 3 killed

Date & Time: Jan 30, 2012 at 0845 LT

Type of aircraft:

PZL-Mielec AN-28

Operator:

Registration:

9Q-CUN

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Democratic Republic of Congo

Schedule:

Bukavu – Namoya

MSN:

1AJ006-11

YOM:

1989

Location:

Namoya

Sud-Kivu

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The twin engine aircraft departed Bukavu-Kavumu Airport at 0745LT for a one-hour cargo flight to Namoya. On approach, the crew encountered marginal weather conditions when the aircraft crashed in a dense wooded area located 10 km short of runway threshold. Two passengers among them a 60 years old women were seriously injured while three other occupants were killed, among them both pilots, a Russian captain and an Indian copilot.

Crash of a Cessna 340A in Ocala: 1 killed

Date & Time: Jan 27, 2012 at 1227 LT

Type of aircraft:

Cessna 340

Operator:

Flying G Aviation

Registration:

N340HF

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Schedule:

Macon - Ocala

MSN:

340A-0624

YOM:

1978

Location:

Ocala

Florida

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:

1048

Aircraft flight hours:

5057

Circumstances:

The pilot entered the left downwind leg of the traffic pattern to land to the north. A surface wind from the west prevailed with gusts to 15 knots. Radar data revealed that the airplane was on final approach, about 1.16 miles from the runway and about 210 feet above the ground. The airplane then crashed in a pasture south of the airport, in a slight left-wing-low attitude, and came to rest upright. The cockpit and cabin were consumed in a postcrash fire. The pilot's wife, who was in the aft cabin and survived the accident, recalled that it was choppy and that they descended quickly. She recalled hearing two distinct warning horns in the cockpit prior to the crash. The airplane was equipped with two aural warning systems in the cockpit: a landing gear warning horn and a stall warning horn. The pilot likely allowed the airspeed to decay while aligning the airplane on final approach and allowed the airplane to descend below a normal glide path. Examination of the wreckage revealed that the landing gear were in transit toward the retracted position at impact, indicating that the pilot was attempting to execute a go-around before the accident. The pilot made no distress calls to air traffic controllers before the crash. The pilot did not possess a current flight review at the time of the accident. Examination of the wreckage, including a test run of both engines, revealed no evidence of a pre-existing mechanical malfunction or failure that would have precluded normal operation of the airplane.

Probable cause:

The pilot's failure to maintain adequate airspeed and altitude on final approach, resulting in an impact with terrain short of the airport.

Final Report:

Crash of a McDonnell Douglas MD-83 in Kandahar

Date & Time: Jan 24, 2012 at 0828 LT

Type of aircraft:

McDonnell Douglas MD-83

Operator:

Registration:

EC-JJS

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Dubai - Kandahar

MSN:

49793/1656

YOM:

1989

Flight number:

SWT094

Location:

Kandahar

Country:

Afghanistan

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4946

Captain / Total hours on type:

3228.00

Copilot / Total flying hours:

2881

Copilot / Total hours on type:

2222

Circumstances:

On Tuesday, 24 January 2012, a McDonnell Douglas MD-83, registration EC-JJS and operated by Swiftair, took off from the Dubai Airport (United Arab Emirates) at 02:08 UTC on a scheduled flight to the Kandahar Airport (Afghanistan). Its callsign was SWT094 and there were 86 passengers (one of them a company mechanic), three flight attendants and two cockpit crew onboard. Swiftair, S.A. was operating this regularly scheduled passenger flight under an ACMI arrangement with the South African company Gryphon Airlines. The crew was picked up at its usual hotel in the emirate of Ras al-Khaimah (United Arab Emirates) at 21:00. The airplane was parked in the Ras al-Khaimah airport and had to be flown empty to the Dubai Airport. This flight departed at 00:20 UTC en route to Dubai. Once there, an agent for Gryphon Airlines gave the crew the documentation for the flight to Kandahar. They went through customs at the Dubai Airport, boarded the passengers and the cargo and refueled the airplane with enough fuel to make the return the flight, a typical practice so as to avoid refueling in Kandahar. The airplane took off from runway 30R at the Dubai Airport at 02:08 on standard instrument departure RIKET2D and climbed to flight level FL290. The first officer was the pilot flying. At 03:42, while over SERKA, they were transferred to Kabul control, which instructed them to descend to FL280. The crew reported its ISAF callsign (ISF39RT) to this ATS station, which allowed the aircraft to fly over Afghan airspace, and entered the new stipulated squawk code. Kabul Control instructed the crew to follow some radar vectors that took them to point SODAS, where they were transferred to Kandahar Control at 03:46. The crew reduced the airspeed to 250 kt above this point. Kandahar Control cleared them for an RNAV (GPS) approach to runway 05, providing a direct vector to point FALOD (the IAF), and to descend to 6,000 ft. The weather information provided on the ATIS “F” broadcast was runway in use 05, wind from 060º at 17 kt gusting to 24 kt, visibility 1,200 m, scattered clouds at 2,700 ft and broken clouds at 3,000 ft, temperature 1 ºC, dewpoint -7 ºC and QNH 30.06 in Hg (1,018 mbar). This information was practically the same as that radioed to the crew by the Kandahar control tower a few minutes before landing: wind from 060 at 15 kt gusting to 21 kt. They reached point FALOD (IAF) under cloud cover (and thus in IMC conditions). They did not exit the clouds until 1,500 ft before minimums which, for this approach, according to the associated chart, was an altitude of 3,700 ft, or 394 ft AGL. They established visual contact with the runway 500 ft above minimums and noted that they were a little right of the runway centerline. Since the captain had more operational experience at the destination airfield, he decided to take over the controls and fly the last phase of the approach maneuver. The PAPI was out of service, meaning that in final approach they only had visual references to the runway and over the ground. During short final they corrected the deviation from the runway centerline by adjusting their path from right to left. They landed at 03:58. During the flare, the crew noticed the airplane was shifting to the left, threatening to take them off the runway, as a result of which the captain applied a right roll angle. This caused the right wing tip to strike the ground before the wheels made contact with the ground. The captain regarded the maneuver as a hard landing, although the first officer thought they might have struck the runway. The autopilot was engaged until visual contact was established with the runway and the auto-throttle until the landing. On exiting the runway, the airport control tower personnel (who had witnessed the contact with the ground) ordered the crew to stop and informed them of the damage they had seen during the landing. They dispatched the emergency services (firefighters), which forced them to turn off their engines. Once it was confirmed that there was no fuel leak or damage to the wheels or brakes, they allowed the crew to restart the engines and proceed to the stand. The wing made contact with the ground some 20 m prior to the threshold, resulting in five threshold lights being destroyed by the aircraft and in damage to the aircraft’s right wing. According to the crew’s statement, the passengers were not really aware of the contact between the wing and the ground and they were subsequently disembarked normally.

Probable cause:

The accident was likely caused by the failure to observe the company's operating procedures and not executing a go-around when the approach was clearly not stabilized. Moreover, the operator lacked the authorization (and the crew the training) to carry out the RNAV (GPS) approach maneuver that was conducted at RWY 05 of the Kandahar Airport.
Contributing to the accident was:
The inoperable status of the PAPI at runway 05 of the Kandahar Airport, which was thus unable to aid the crew to establish the aircraft on the correct descent slope.

Final Report:

Crash of a Piper PA-31T Cheyenne II in Puerto Montt

Date & Time: Jan 19, 2012 at 2100 LT

Type of aircraft:

Piper PA-31 Cheyenne

Operator:

Registration:

CC-PLL

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Site:

Puerto Montt-Marcel Marchant (La Paloma)

Schedule:

Santiago – Puerto Montt

MSN:

31-7920005

YOM:

1979

Location:

Región de Los Lagos

Country:

Chile

Region:

South America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

30353

Captain / Total hours on type:

972.00

Aircraft flight hours:

6989

Circumstances:

The twin engine aircraft departed Santiago-Eulogio Sánchez Errázuriz-Tobalaba Airport at 1815LT on a flight to Puerto Montt, carrying seven passengers and one pilot. On approach to Puerto Montt-Marcel Marchant Airport runway 19, his attention was focused on the GPS and he forgot to lower the landing gear. The aircraft belly landed and slid for few dozen metres before coming to rest on the main runway. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

Belly landing on runway 19 after the pilot forgot to lower the landing gear while approaching the airport.
The following contributing factors were identified:
- Probable distraction of the pilot by keeping his attention mainly on the GPS equipment to maintain the flight path and avoid unnecessary engine power adjustments,
- The pilot failed to follow the approach and landing checklist,
- The pilot failed to check the three gear lights on the cockpit panel,
- The pilot performed an unstabilized approach without completing the pre-landing checklist and eventually stabilized the airplane at a height of 500 feet.

Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Welshpool: 2 killed

Date & Time: Jan 18, 2012 at 1117 LT

Type of aircraft:

Piper PA-31-310 Navajo

Operator:

Registration:

G-BWHF

Flight Phase:

Flight Type:

Training

Survivors:

Site:

Rockwell Aero Commander 500

Schedule:

Welshpool - Welshpool

MSN:

31-7612076

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11164

Captain / Total hours on type:

375.00

Copilot / Total flying hours:

17590

Copilot / Total hours on type:

2177

Circumstances:

The commander had retired from flying Commercial Air Transport operations with an airline in August 2011. He had recently renewed his single pilot Instrument Rating and Multi Engine Piston (Land) planes rating and his intention was to continue flying part-time. He had been invited to fly G‑BWHF, which was privately operated for business purposes, but his last flight in this aircraft was on 10 November 1998. Accordingly, he planned to conduct a re-familiarisation flight. The commander was accompanied by another pilot who was not a flight instructor but had recent experience of flying the aircraft and was familiar with the aerodrome. A webcam recorded the pilots towing the aircraft to the refuelling point, refuelling it and carrying out pre‑flight preparations. There were no witnesses to any briefings which may have taken place. The commander first started the right engine, which initially ran roughly and backfired before running smoothly. The left engine started normally. The second pilot took his place in the front right seat. The aircraft taxied to the holding point of Runway 22, and was heard by witnesses to be running normally. A witness who lived adjacent to the airfield but could not see the aircraft heard the power and propeller checks being carried out, three or four times instead of once per engine as was usual. The engines were heard to increase power and the witness observed the aircraft accelerate along the runway and takeoff at 1105 hrs. It climbed straight ahead and through a small patch of thin stratus cloud, the base of which the witness estimated was approximately 1,000 ft aal. The aircraft remained visible as it passed through the cloud and continued climbing. The witness turned away from the aircraft to continue working but stated that apart from the unusual number of run-up checks, the aircraft appeared and sounded normal. The pilot of a Robinson R22 helicopter which departed Welshpool at 1015 hrs described weather to the south of the aerodrome as drizzle with patches of broken stratus at 600-700 ft aal. He was able to climb the helicopter between the patches of stratus until, at 1,500 ft, he was above the tops of the cloud. Visibility below the cloud was approximately 5-6 km but, above the cloud, it was in excess of 10 km. He noted that the top of Long Mountain was in cloud and his passenger took a photograph of the Long Mountain area The R22 returned to the airfield and joined left hand downwind for Runway 22. As it did so, its pilot heard a transmission from the pilot of the PA-31 stating that he was rejoining for circuits. The R22 pilot transmitted his position in order to alert the PA-31, then continued around the circuit and called final before making his approach to the runway, landing at about 1115 hrs. After passing overhead Welshpool, it made a descending left circuit, becoming established on a left hand, downwind leg for Runway 22. A witness approximately 3.5 nm northeast of the accident site saw the aircraft coming towards him with both propellers turning. It made a turn to the left with the engines apparently at a high power setting and, as it passed over Long Mountain, commenced a descent. He could not recall whether he could still hear the engines as the aircraft descended. He then lost sight of it behind the rising ground of Long Mountain. A search was initiated when the aircraft failed to return to Welshpool. Its wreckage was located in an open field on the west slope of Long Mountain. There were no witnesses to the actual impact with the trees or surface of the field but the sound was heard by a witness in the wood who stated that the engines were audible immediately prior to impact. The accident, which was not survivable, occurred at 1117 hrs. Both pilots were fatally injured.

Probable cause:

The aircraft struck the tops of the trees located on the upper slope of Long Mountain, while descending for a visual approach to land on Runway 22 at Welshpool Airport. The trees were probably not visible to the pilots because of cloud covering the upper slopes.

Final Report:

Crash of a Rockwell Aero Commander 500B in Bartlesville

Date & Time: Jan 13, 2012 at 1930 LT

Type of aircraft:

Operator:

Registration:

N524HW

Flight Phase:

Flight Type:

Positioning

Survivors:

Site: