Crash of an Antonov AN-24RV in Blagoveshchensk

Date & Time: Aug 8, 2011 at 1412 LT
Type of aircraft:
Operator:
Registration:
RA-46561
Survivors:
Yes
Schedule:
Irkutsk - Chita - Blagoveshchensk - Khabarovsk
MSN:
67310609
YOM:
1976
Flight number:
RD103
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11555
Captain / Total hours on type:
6722.00
Copilot / Total flying hours:
3268
Copilot / Total hours on type:
575
Aircraft flight hours:
12346
Aircraft flight cycles:
13767
Circumstances:
Following an uneventful flight from Chita, the crew initiated the approach to Blagoveshchensk in poor weather conditions with reduced visibility, heavy rain falls, thunderstorm activity and a cloud base at 150 metres. On final approach, despite he did establish any visual contact with the runway or its light system, the captain continued the approach and passed below the MDA. As the aircraft was not properly aligned with the runway centerline, it descended too low and impacted trees 210 meters to the right of the centerline and 50 meters short of runway 36. Upon impact, the left wing was torn off and the aircraft crashed in a wooded area. It slid over a distance of 450 metres before coming to rest. There was no fire. All 41 occupants were rescued, among them 9 were injured.
Probable cause:
The probable causes of the accident were the failure of the crew to go around and the descent well below decision height without visual reference to landmarks when the aircraft approached the airfield in weather conditions below the captain's, aircraft's and airfield's minima and in dangerous/adverse weather phenomena like thunderstorm, heavy rain and severe turbulence as well as the lack of appropriate response and required actions following terrain awareness warning system alerts resulted in a controlled flight into terrain, collision with obstacles and the destruction of the aircraft.
Contributing factors:
- the crew underestimated the weather conditions at the destination airport thus taking an erroneous decision to attempt an approach in thunderstorm and heavy rain showers,
- unsatisfactory meteorological support of the flight, the dispatcher and later air traffic control provided information about visibility, cloud and wind data that did not correspond to actual conditions that were significantly worse than minimums required,
- clearance for the approach by air traffic control despite the presence of dangerous weather phenomena (thunderstorm, heavy rain) at the aerodrome, which did not correspond to the standard operating procedures at Blagoveshchensk,
- inadequate staffing with a first officer who was performing his first flight after a prolonged leave without proper preparation and training,
- unsatisfactory crew interaction and the failure to adhere to standard operating procedures, especially the call outs of approaching decision height, the absence of a decision by the commander to continue the landing or go-around and the lack of action to recommend/initiate a go around by the first officer.
Final Report:

Crash of a Convair CV-580 in Kasba Lake

Date & Time: Aug 3, 2011 at 1100 LT
Type of aircraft:
Operator:
Registration:
C-GKFP
Survivors:
Yes
Schedule:
Winnipeg – Kasba Lake
MSN:
446
YOM:
1956
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Winnipeg, the crew completed the landing on runway 02/20, a 1,876 metres long clay/gravel runway. During the landing roll, the nose gear collapsed. The aircraft slid on its nose for few dozen metres before coming to rest. All occupants evacuated safely and the aircraft was damaged beyond repair. At the time of the accident, the runway surface was irregular with potholes and water gouges due to the recent rains.

Crash of a Boeing 737-8BK in Georgetown

Date & Time: Jul 30, 2011 at 0132 LT
Type of aircraft:
Operator:
Registration:
9Y-PBM
Survivors:
Yes
Schedule:
New York - Port of Spain - Georgetown
MSN:
29635/2326
YOM:
2007
Flight number:
BW523
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9600
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
1400
Copilot / Total hours on type:
350
Aircraft flight hours:
14861
Circumstances:
The flight originated in New York as BW 523, and made a passenger and fuel stop in Port-of-Spain, Trinidad where there was also a change of crew comprising two pilots and four flight attendants before proceeding to Georgetown, Guyana. The flight departed Piarco at 04:36UTC. The aircraft proceeded to Georgetown from Port of Spain at Flight Level (FL) 330, was given descent clearance and was cleared for an RNAV (GPS) approach to RWY 06, landing at 05:32 UTC. There were no reported anomalies in the en-route profile, although during the transition from cruise to approach to RWY 06 the aircraft deviated to avoid some thunderstorm cells north and east of the Airport. The reported visibility was 9,000m. Light rain was encountered during the approach. The pilot reported that after visual contact was made and after crossing the Final Approach Fix (FAF), he disengaged the auto pilot and configured the aircraft for landing. The Flight Data Recorder (FDR) indicated that the flight was normal until the aircraft was approaching the runway. Even before the aircraft was over the threshold, the captain commented that he was not landing here. As the flight continued over the runway, comments on the Cockpit Voice Recorder (CVR), revealed that the captain indicated to the First Officer (FO) that the aircraft was not touching down. A go-around call was made by the Captain and acknowledged by the First Officer, however three seconds elapsed and the aircraft subsequently touched down approximately 4700ft from the threshold of RWY06, leaving just over 2700 feet of runway surface remaining. Upon touchdown, brake pressure was gradually increased and maximum brake pressure of 3000psi was not achieved until the aircraft was 250ft from the end of the runway or 450ft from the end of the paved area. The ground spoilers were extended on touchdown. The thrust reversers were partially deployed after touchdown. The aircraft did not stop and overran the runway. It then assumed a downward trajectory followed by a loud impact.
Probable cause:
The probable cause of the accident was that the aircraft touched down approximately 4,700 feet beyond the runway threshold, some 2,700 feet from the end of the runway, as a result of the Captain maintaining excess power during the flare, and upon touching down, failure to utilize the aircraft’s full deceleration capability, resulted in the aircraft overrunning the remaining runway and fracturing the fuselage.
Contributory Factors:
The Flight Crew’s indecision as to the execution of a go-around, failure to execute a go-around after the aircraft floated some distance down the runway and their diminished situational awareness contributed to the accident.
Final Report:

Crash of a Lockheed C-130H Hercules in Guelmim: 80 killed

Date & Time: Jul 26, 2011 at 0900 LT
Type of aircraft:
Operator:
Registration:
CNA-OQ
Flight Type:
Survivors:
No
Site:
Schedule:
Dakhla - Guelmim - Kenitra
MSN:
4892
YOM:
1981
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
72
Pax fatalities:
Other fatalities:
Total fatalities:
80
Circumstances:
The four engine aircraft departed Dakhla on a flight to Kenitra with an intermediate stop in Guelmim, carrying 60 soldiers, 12 civilians and 8 crew members. While approaching Guelmim Airport, the pilot encountered poor visibility due to marginal weather conditions. Too low, the aircraft impacted the slope of a rocky mountain located 10 km short of runway. The aircraft was totally destroyed by impact forces and a post crash fire. Two passengers survived the accident but died the following day.

Crash of a Cessna 208 Caravan I in Kei Mouth

Date & Time: Jul 23, 2011
Type of aircraft:
Operator:
Registration:
3009
Flight Type:
Survivors:
Yes
Schedule:
Swartkop AFB - Kei Mouth
MSN:
208-0159
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Kei Mouth Airport in the Eastern Cape Province, the single engine aircraft crashed in unknown circumstances. While both occupants were uninjured, the aircraft was damaged beyond repair. The crew was completing a positioning flight from Swartkop AFB.

Crash of an ATR72-212 in Shannon

Date & Time: Jul 17, 2011 at 1021 LT
Type of aircraft:
Operator:
Registration:
EI-SLM
Survivors:
Yes
Schedule:
Manchester - Shannon
MSN:
413
YOM:
1994
Flight number:
EI3601
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2882
Captain / Total hours on type:
2444.00
Copilot / Total flying hours:
1678
Copilot / Total hours on type:
1351
Aircraft flight hours:
32617
Aircraft flight cycles:
37149
Circumstances:
The aircraft and crew commenced operations in EINN that morning, departing at 05.52 hrs and arriving at EGCC at 07.13 hrs. During the turnaround, fuel was uplifted and 21 passengers boarded. Using the flight number and call sign EI-3601 the scheduled passenger service departed EGCC at 07.47 hrs for EINN with an estimated flight time of one hour and nine minutes. En-route operations were normal and, in consultation with ATC, the aircraft descended and was cleared to self-position to DERAG2 for an Instrument Landing System (ILS) approach to RWY 24. At 09.08 hrs the aircraft commenced an approach to RWY 24 in strong and gusty crosswind conditions. Following a turbulent approach difficulty was experienced in landing the aircraft, which contacted the runway in a nose-down attitude and bounced. A go-around was performed and the aircraft was vectored for a second approach. During this second approach landing turbulence was again experienced. Following bounces the aircraft pitched nose down and contacted the runway heavily in a nose down attitude. The nose gear collapsed and the aircraft nose descended onto the runway. The aircraft sustained damage with directional control being lost. The aircraft came to rest at the junction of the runway and a taxiway. Following engine shutdown the forward Cabin Crew Member (CCM) advised the cockpit that there was no smoke and that the doors could be opened following which, an evacuation was commenced. Airport fire crews arrived on scene promptly and assisted passengers disembarking the aircraft. There were no injuries.
Probable cause:
Probable Cause:
1. Excessive approach speed and inadequate control of aircraft pitch during a crosswind landing in very blustery conditions.
Contributory Factors:
1. Confusing wording in the FCOM that led the crew to compute an excessive wind factor in the determination of Vapp.
2. Incorrect power handling technique while landing.
3. Inexperience of the pilot in command.
4. Inadequate information provided to flight crew regarding crosswind landing techniques.
Final Report:

Crash of a Cessna 560XL Citation XLS in Port Harcourt

Date & Time: Jul 14, 2011 at 1953 LT
Operator:
Registration:
5N-BMM
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
560-5830
YOM:
2008
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11751
Captain / Total hours on type:
684.00
Copilot / Total flying hours:
13302
Copilot / Total hours on type:
612
Aircraft flight hours:
982
Circumstances:
5N-BMM departed Lagos at 1856 hrs for Port Harcourt on an Instrument Flight Rules (IFR) and estimated Port Harcourt at 1940 hrs. The aircraft was cleared to maintain FL330. The aircraft’s first contact with Port Harcourt was at 1914 hrs. The pilot reported maintaining FL330 with six souls onboard, four hours fuel endurance and estimating POT VOR at 1940hrs. The aircraft was cleared to POT, to maintain FL330 with no delay expected for ILS Approach Runway 21, QNH 1011 and to report when released by Lagos. At 1921 hrs the pilot reported 100 NM to POT and requested for descent. The aircraft was cleared to descend to FL150. At 1927 hrs the pilot requested for further descent and was cleared to 3,300 feet on QNH 1011 but the pilot acknowledged 3500 feet. At 1931 hrs the aircraft was re-cleared to FL090 initially due to departing traffic on Runway 03. At 1934 hrs 5N-BMM reported maintaining FL090 and was re-cleared to FL050. The aircraft was re-cleared to 2,000 feet on QNH 1011 at 1936 hrs and cleared for the straight-in ILS Approach Runway 21 and to report on the localizer. At 1947 hrs the pilot reported final for Runway 21 and was asked to contact Tower on 119.2 and the Tower asked 5N-BMM to report on glide slope Runway 21. At 1950 hrs the Tower asked 5N-BMM to confirm on the glide slope and the crew confirmed “Charlie, we have three miles to run”. The Tower cleared 5N-BMM to land with surface wind calm but to exercise caution since the Runway surface was wet and 5N-BMM responded “wind calm”. At 1952:26 hrs the auto voice callout "minimums minimums” alerted the crew. At 1952:40 hrs the pilot flying (PF) said "I am not on the centerline". At 1952:48 hrs he said "I can't see down". At 1952:55 hrs the pilot monitoring (PM) said to the pilot flying; " I am telling you to go down" and the pilot flying said " I will go down", five seconds later the aircraft crashed. The crew exited the aircraft without accomplishing the Emergency Evacuation Checklist and therefore left the right engine running for about 28 minutes after the crash. The Fire Service eventually used their water hose to shutdown the running engine. At 19:54 hrs the Tower called 5N-BMM to pass on the landing time as 19:53 hrs, but no response from 5N-BMM. There was no indication that the aircraft was taxing on the Runway because it was dark and no light was visible hence the need to alert the Fire personnel. The watch room was asked to give the Tower information, which they could not give since they do not have a two – way contact with the Fire trucks. The Tower could not raise the Fire truck since there was no two - way communication between them; however, the Fire truck was later cleared to proceed to the Runway as the Tower could not ascertain the position of the aircraft. The aircraft was actually turned 90° because of the big culvert that held the right wing and made the aircraft spin and turned 90o facing the runway, two meters from the active runway, the culvert was uprooted due to the aircraft impact forces. The wheel broke off because of the gully that runs parallel to the runway.
Probable cause:
The decision of the pilot to continue the approach without the required visual references.
Contributory Factors:
- Poor crew coordination (CRM),
- Pairing two captains together,
- The weather was marginal.
Final Report:

Crash of an Antonov AN-24RV in Strezhevoy: 7 killed

Date & Time: Jul 11, 2011 at 1156 LT
Type of aircraft:
Operator:
Registration:
RA-47302
Survivors:
Yes
Schedule:
Tomsk - Surgut
MSN:
5 73 103 02
YOM:
1975
Flight number:
IK9007
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
4570
Captain / Total hours on type:
4064.00
Copilot / Total flying hours:
9476
Copilot / Total hours on type:
5100
Aircraft flight hours:
48489
Aircraft flight cycles:
32783
Circumstances:
The twin engine aircraft departed Tomsk Airport at 1010LT on a flight (callsign IK9007/SP5007) to Surgut, carrying 33 passengers and a crew of four. About an hour and 26 minutes into the flight, the left engine's 'chips in oil' warning light came on. About eight minutes later, a burning smell was noticed in the cockpit and the captain decided to divert to Nizhnevartovsk Airport. During the descent, the left engine caught fire. Its propeller was feathered and the crew decided to divert to Strezhevoy Airport. But as the fire could not be extinguished, the captain eventually attempted an emergency landing in the Ob River. Upon landing, the aircraft broke in two and came to rest in shallow water. Seven passengers were killed while all other occupants were rescued.
Probable cause:
The Interstate Aviation Committee (MAK) released their final report in Russian concluding the probable causes of the accident were:
The catastrophe of the AN-24 RA-47302 occurred when ditching became necessary due to a fire in the left hand engine's nacelle. The destruction of the aircraft and loss of life was caused by collision with underwater obstacles that the crew could not anticipate or avoid. The fire in the left hand engine nacelle was caused by the fracture of a centrifugal breather releasing an air-fuel emulsion into the engine compartment as well as a delayed reaction to shut the engine down by the crew following an magnetic chip detector indication together with indications of oil pressure fluctuations, a burning smell and a low oil pressure indication. A delay in indicating engine vibrations to the crew as result of degradation of the engine vibration sensoring equipment, most likely caused by changes of the rotor speed of the engine as result of the aft bearing failure of the compressor rotor and/or misalignment of the sensor, which probably influenced the decision of the crew to shut the engine down with a delay. Cause of the fracture of the centrifugal breather was the destruction of the impeller due to prolonged exposure to hot air-fuel emulsion due to the failure of the aft compressor rotor support bearing. It was not possible to determine the cause of the destruction of the aft compressor rotor support bearing due to significant secondary damage. Most likely the destruction was caused by misalignment such as:
- Incorrect assembly of support parts mating with the compressor rotor during on-condition engine repairs,
- Or deviations from required geometry of support parts mating with the compressor rotor.
Contributing factors were:
- Psychological unpreparedness of the captain to shut the engine down due to lack of experience with the aircraft on one engine inoperative
- Late detection of the fire and as a consequence late attempts to extinguish the fire, it was however not possible to establish why the fire was detected late due to lack of objective information about the performance of the fire alarm systems.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 310 in the Maadhiggaru Falhu lagoon

Date & Time: Jul 11, 2011 at 0910 LT
Operator:
Registration:
8Q-TMD
Flight Type:
Survivors:
Yes
Schedule:
Male - Male
MSN:
530
YOM:
1977
Flight number:
TMW201A
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5732
Captain / Total hours on type:
3387.00
Copilot / Total flying hours:
2650
Copilot / Total hours on type:
2650
Aircraft flight hours:
34746
Aircraft flight cycles:
62428
Circumstances:
The 8Q-TMD aircraft took-off from water runway of Male’ International Airport North Bound Left (NL) at 0820 hrs local time on 11 July 2011 for a routine training flight bound to Maadhiggaru Falhu (a lagoon located approximately 15 nautical miles south west of the Male’ International Airport). The sky was clear with good visibility and wind 8-10 knots from west and south west. During the training 5 landings and take-offs were made simulating different conditions of flight. Crew confirmed that all these landings and take-offs were made inside the lagoon except the last landing where the crew decided to land on open water outside the lagoon. Crew were simulating single engine landing with a tail wind. As per the crew, the aircraft initial touch down was smooth. However, they stroke a wave which made the aircraft bounce up for about 20 feet. With the low power the aircraft hit the water again, resulting in multiple float attachments to break. Both front and main spreader bars broke and floats rose up twisted, hitting the engine bottom cowlings. Propeller cut was found on top front of both floats.
Probable cause:
Impact with a high swell during landing followed by a high bounce and hard landing resulting in both float attachments being damaged and detached with a major structural damages. Major contributing factor was higher than normal touch down speed due to abnormal landing configuration.
Contributing factors:
- Selection of inappropriate landing site (channel) and landing direction (tail wind) based on surface conditions present at that time,
- Simulation of multiple emergencies,
- Abnormal landing configuration (flaps at zero) for single engine landing,
- Time pressure to complete the training and return to commercial operations.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Demopolis: 7 killed

Date & Time: Jul 9, 2011 at 1740 LT
Registration:
N692TT
Flight Type:
Survivors:
No
Schedule:
Creve Cœur – Destin
MSN:
421C-0616
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
1000
Captain / Total hours on type:
340.00
Aircraft flight hours:
7800
Circumstances:
The multi-engine airplane was in cruise flight at flight level 210 when the pilot declared an emergency due to a rough-running right engine and diverted to a non-towered airport about 10 miles from the airplane’s position. About 4 minutes later, the pilot reported that he had shut down the right engine. The pilot orbited around the diversion airport during the descent and reported to an air traffic controller that he did not believe he would require any assistance after landing. The airplane initially approached the airport while descending through about 17,000 feet mean sea level (msl) and circled above the airport before entering a left traffic pattern approach for runway 22. About 7,000 feet msl, the airplane was about 2.5 miles northeast of the airport. The airplane descended through 2,300 feet msl when it was abeam the runway threshold on the downwind leg of the traffic pattern. According to the airplane information manual, procedures for landing with an inoperative engine call for “excessive altitude;” however, the airplane's last radar return showed the airplane at an altitude of 700 feet msl (about 600 feet above ground level) and about 3 miles from the approach end of the runway. The airplane was configured for a single-engine landing and was likely on or turning to the final approach course when it rolled and impacted trees. The airplane came to rest in a wooded area about 0.8 miles north of the runway threshold, inverted, in a flat attitude with no longitudinal deformation. A majority of the airplane, including the cockpit, main cabin, and left wing, were consumed by a postcrash fire. Search operations located the airplane about 6 hours after its expected arrival time. Due to the severity of the postcrash fire, occupant survivability after the impact could not be determined. Examination of the airframe, the left engine, and both propellers did not reveal any preaccident mechanical malfunctions or failures that would have precluded normal operation. The investigation revealed that the right engine failed when the camshaft stopped rotating after the camshaft gear experienced a fatigue fracture on one of its gear teeth. The remaining gear teeth were fractured in overstress and/or were crushed due to interference contact with the crankshaft gear. Spalling observed on an intact gear tooth suggested abnormal loading of the camshaft gear; however, the origin of the abnormal loading could not be determined.
Probable cause:
The pilot's failure to maintain airplane control during a single-engine approach and his failure to fly an appropriate traffic pattern for a single-engine landing. Contributing to the accident was a total loss of engine power on the right engine due to a fatigue failure of the right engine cam gear.
Final Report: