Crash of a Beechcraft 100 King Air in Kirby Lake: 1 killed

Date & Time: Oct 25, 2010 at 1120 LT
Type of aircraft:
Operator:
Registration:
C-FAFD
Survivors:
Yes
Schedule:
Calgary - Edmonton - Kirby Lake
MSN:
B-42
YOM:
1970
Flight number:
KBA103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The aircraft was on an instrument flight rules flight from the Edmonton City Centre Airport to Kirby Lake, Alberta. At approximately 1114 Mountain Daylight Time, during the approach to Runway 08 at the Kirby Lake Airport, the aircraft struck the ground, 174 feet short of the threshold. The aircraft bounced and came to rest off the edge of the runway. There were 2 flight crew members and 8 passengers on board. The captain sustained fatal injuries. Four occupants, including the co-pilot, sustained serious injuries. The 5 remaining passengers received minor injuries. The aircraft was substantially damaged. A small, post-impact, electrical fire in the cockpit was extinguished by survivors and first responders. The emergency locator transmitter was activated on impact. All passengers were BP employees.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The conduct of the flight crew members during the instrument approach prevented them from effectively monitoring the performance of the aircraft.
2. During the descent below the minimum descent altitude, the airspeed reduced to a point where the aircraft experienced an aerodynamic stall and loss of control. There was insufficient altitude to effect recovery prior to ground impact.
3. For unknown reasons, the stall warning horn did not activate; this may have provided the crew with an opportunity to avoid the impending stall.
Findings as to Risk:
1. The use of company standard weights and a non-current aircraft weight and balance report resulted in the flight departing at an inaccurate weight. This could result in a performance regime that may not be anticipated by the pilot.
2. Flying an instrument approach using a navigational display that is outside the normal scan of the pilot increases the workload during a critical phase of flight.
3. Flying an abbreviated approach profile without applying the proper transition altitudes increases the risk of controlled flight into obstacles or terrain.
4. Not applying cold temperature correction values to the approach altitudes decreases the built-in obstacle clearance parameters of an instrument approach.
Final Report:

Crash of a PZL-Mielec AN-2T in Santa Isabel

Date & Time: Oct 24, 2010 at 1145 LT
Type of aircraft:
Operator:
Registration:
CX-CAP
Survivors:
Yes
Schedule:
Santa Isabel - Santa Isabel
MSN:
1G142-31
YOM:
1973
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1200
Captain / Total hours on type:
100.00
Aircraft flight hours:
4339
Circumstances:
The single engine aircraft was engaged in a local skydiving mission in Santa Isabel, carrying nine skydivers and one pilot. Shortly after takeoff, while climbing to a height of about 150 metres, the engine lost power. The pilot decided to return immediately. Upon landing, the aircraft collided with bushes and came to rest, bursting into flames. All 10 occupants escaped unhurt while the aircraft was totally destroyed by fire.
Probable cause:
The exact cause of the accident could not be determined.
Final Report:

Crash of a Harbin Yunsunji Y-12-II in Mukinge

Date & Time: Oct 16, 2010
Type of aircraft:
Operator:
Registration:
AF-215
Flight Type:
Survivors:
Yes
Schedule:
Lusaka – Mukinge
MSN:
0088
YOM:
1994
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Lusaka on a flight to Mukinge, carrying staff and various goods on behalf of the Zambian Presidency. After touchdown, the aircraft veered off runway and came to rest against trees. All occupants escaped uninjured while the aircraft was damaged beyond repair. The crew was flying to Mukinge, preparing the next official visit of the President of the Republic of Zambia Rupiah Banda.

Crash of a Gippsland GA8 Airvan in Lady Barron

Date & Time: Oct 15, 2010 at 1715 LT
Type of aircraft:
Operator:
Registration:
VH-DQP
Survivors:
Yes
Site:
Schedule:
Lady Barron - Bridport
MSN:
GA8-05-075
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2590
Captain / Total hours on type:
1355.00
Circumstances:
The pilot was conducting a charter flight from Lady Barron, Flinders Island to Bridport, Tasmania with six passengers on board. The aircraft departed Lady Barron Aerodrome at about 1700 Australian Eastern Daylight-saving Time and entered instrument meteorological conditions (IMC) several minutes afterwards while climbing to the intended cruising altitude of about 1,500 ft. The pilot did not hold a command instrument rating and the aircraft was not equipped for flight in IMC. He attempted to turn the aircraft to return to Lady Barron Aerodrome but became lost, steering instead towards high ground in the Strzelecki National Park in the south-east of Flinders Island. At about 1715, the aircraft exited cloud in the Strzelecki National Park, very close to the ground. The pilot turned to the left, entering a small valley in which he could neither turn the aircraft nor out climb the terrain. He elected to slow the aircraft to its stalling speed for a forced landing and, moments later, it impacted the tree tops and then the ground. The first passenger to exit the aircraft used the aircraft fire extinguisher to put out a small fire that had begun beneath the engine. The other passengers and the pilot then exited the aircraft safely. One passenger was slightly injured during the impact; the pilot and other passengers were uninjured. During the night, all of the occupants of the aircraft were rescued by helicopter and taken to the hospital in Whitemark, Flinders Island.
Probable cause:
Contributing safety factors:
• The weather was marginal for flight under the visual flight rules, with broken cloud forecast down to 500 ft above mean sea level in the area.
• The pilot, who did not hold a command instrument rating, entered instrument meteorological conditions because he was adhering to an un-written operator rule not to fly below 1,000 ft above ground level.
• The pilot became lost in cloud and flew the aircraft towards the Mt Strzelecki Range, exiting the cloud in very close proximity to the terrain.
• The aircraft exited the cloud in a small valley, within which the pilot could neither turn round nor out-climb the terrain.
Other key findings:
• The aircraft exited cloud before impacting terrain and with sufficient time for the pilot to execute a forced landing.
• The design of the aircraft’s seats, and the provision to passengers in the GA-8 Airvan of three-point automotive-type restraint harnesses with inertia reel shoulder straps contributed to the passengers’ survival, almost without injury.
Final Report:

Crash of a Cessna 550 Citation II in Manteo

Date & Time: Oct 1, 2010 at 0830 LT
Type of aircraft:
Operator:
Registration:
N262Y
Survivors:
Yes
Schedule:
Tampa - Manteo
MSN:
550-0291
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9527
Captain / Total hours on type:
2025.00
Copilot / Total flying hours:
3193
Copilot / Total hours on type:
150
Aircraft flight hours:
9643
Circumstances:
According to postaccident written statements from both pilots, the pilot-in-command (PIC) was the pilot flying and the copilot was the pilot monitoring. As the airplane approached Dare County Regional Airport (MQI), Manteo, North Carolina, the copilot obtained the current weather information. The automated weather system reported wind as 350 degrees at 4 knots, visibility at 1.5 miles in heavy rain, and a broken ceiling at 400 feet. The copilot stated that the weather had deteriorated from the previous reports at MQI. The PIC stated that they would fly one approach to take a look and that, if the airport conditions did not look good, they would divert to another airport. Both pilots indicated in phone interviews that, although they asked the Washington air route traffic control center controller for the global positioning system (GPS) runway 5 approach, they did not expect it due to airspace restrictions. They expected and received a GPS approach to runway 23 to circle-to-land on runway 5. According to the pilots' statements, the airplane was initially fast on approach to runway 23. As a result, the copilot could not deploy approach flaps when the PIC requested because the airspeed was above the flap operating range. The PIC subsequently slowed the airplane, and the copilot extended flaps to the approach setting. The PIC also overshot an intersection but quickly corrected and was on course about 1 mile prior to the initial approach fix. The airplane crossed the final approach fix on speed (Vref was 104) at the appropriate altitude, with the flaps and landing gear extended. The copilot completed the approach and landing checklist items but did not call out items because the PIC preferred that copilots complete checklists quietly. The PIC then stated that they would not circle-to-land due to the low ceiling. He added that a landing on runway 23 would be suitable because the wind was at a 90-degree angle to the runway, and there was no tailwind factor. Based on the reported weather, a tailwind component of approximately 2 knots existed at the time of the accident, and, in a subsequent statement to the Federal Aviation Administration, the pilot acknowledged there was a tailwind about 20 degrees behind the right wing. The copilot had the runway in sight about 200 feet above the minimum descent altitude, which was 440 feet above the runway. The copilot reported that he mentally prepared for a go around when the PIC stated that the airplane was high about 300 feet above the runway, but neither pilot called for one. The flight crew stated that the airplane touched down at 100 knots between the 1,000-foot marker and the runway intersection-about 1,200 feet beyond the approach end of the 4,305-foot-long runway. The speed brakes, thrust reversers, and brakes were applied immediately after the nose gear touched down and worked properly, but the airplane departed the end of the runway at about 40 knots. According to data extracted from the enhanced ground proximity warning system, the airplane touched down about 1,205 feet beyond the approach end of the 4,305-foot-long wet runway, at a ground speed of 127 knots. Data from the airplane manufacturer indicated that, for the estimated landing weight, the airplane required a landing distance of approximately 2,290 feet on a dry runway, 3,550 feet on a wet runway, or 5,625 feet for a runway with 0.125 inch of standing water. The chart also contained a note that the published limiting maximum tailwind component for the airplane is 10 knots but that landings on precipitation-covered runways with any tailwind component are not recommended. The note also indicates that if a tailwind landing cannot be avoided, the above landing distance data should be multiplied by a factor that increases the wet runway landing distance to 3,798 feet, and the landing distance for .125 inch of standing water to 6,356 feet. All distances in the performance chart are based on flying a normal approach at Vref, assume a touchdown point 840 feet from the runway threshold in no wind conditions, and include distance from the threshold to touchdown. The PIC's statement about the airplane being high at 300 feet above the runway reportedly prompted the copilot to mentally prepare for a go around, but neither pilot called for one. However, the PIC asked the copilot what he thought, and his reply was " it's up to you." The pilots touched down at an excessive airspeed (23 knots above Vref), more than 1,200 feet down a wet 4,305-foot-long runway, leaving about 3,100 feet for the airplane to stop. According to manufacturer calculations, about 2,710 feet of ground roll would be required after the airplane touched down, assuming a touchdown speed at Vref; a longer ground roll would be required at higher touchdown speeds. Although a 2 knot crosswind component existed at the time of the accident, the airplane's excessive airspeed at touchdown (23 knots above Vref) had a much larger effect on the outcome of the landing.
Probable cause:
The pilot-in-command's failure to maintain proper airspeed and his failure to initiate a go-around, which resulted in the airplane touching down too fast on a short, wet runway and a subsequent runway overrun. Contributing to the accident was the copilot's failure to adequately monitor the approach and call for a go around and the flight crew's lack of proper crew resource management.
Final Report:

Crash of an Airbus A319-132 in Palermo

Date & Time: Sep 24, 2010 at 2007 LT
Type of aircraft:
Operator:
Registration:
EI-EDM
Survivors:
Yes
Schedule:
Rome - Palermo
MSN:
2424
YOM:
2005
Flight number:
JET243
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13860
Captain / Total hours on type:
2918.00
Copilot / Total flying hours:
1182
Copilot / Total hours on type:
937
Aircraft flight hours:
15763
Aircraft flight cycles:
8936
Circumstances:
Following an uneventful flight from Rome-Fiumicino Airport, the crew started a night approach to Palermo-Punta Raisi Airport in poor weather conditions with heavy rain falls, thunderstorm activity and reduced visibility. During the descent, weather information was transmitted to the crew, indicating a visibility of 4 km with few CB's at 1,800 feet and a windshear warning for runway 20. On final approach, at an altitude of 810 feet (100 feet above MDA), following the 'minimum' call, the captain instructed the copilot to continue the approach despite the copilot did not establish a visual contact with the runway. At an altitude of 240 feet, the copilot reported the runway in sight but informed the captain that all four PAPI's lights were red. The captain took over control and continued the approach after the airplane deviated from the descent profile. With an excessive rate of descent of 1,360 feet per minute, the aircraft impacted ground 367 metres short of runway 07 threshold and collided with the runway 25 localizer antenna. Upon impact, both main landing gear were partially torn off. The aircraft slid for about 850 metres before coming to rest on the left of the runway. All 129 occupants were rescued, among them 35 were injured. The aircraft was damaged beyond repair.
Probable cause:
The event is classified as short landing accident and the cause is mainly due to human factors. The fact that the aircraft contacted the ground took place about 367 meters short of the runway threshold was due to the crew's decision to continue the instrument approach without a declared shared acquisition of the necessary visual references for the completion of the non-precision procedure and of the landing maneuver. The investigation revealed no elements to consider that the incident occurred due to technical factors inherent in the aircraft.
The following contributing factors were identified:
- The poor attitude of those present in the cockpit to use of basics of CRM, particularly with regard to interpersonal and cognitive abilities of each and, overwhelmingly, the commander.
- Deliberate failure to comply with SOP in place which provided, reaching the MDA, to apply the missed approach procedure where adequate visual reference of the runway in use had not been in sight of both pilots.
- Failure to apply, by those present in the cockpit, the operators rules, concerning in particular: the concept of "sterile cockpit"; to do the descent briefing; to make callouts on final approach.
- The routine with the crew, carrying out approaches to Palermo-Punta Raisi Airport, from which the complacency to favor the personalization of the standards set by operator, and by law. The complacency is one of the most insidious aspects in the context of the human factor, as it creeps in individual self-satisfaction of a condition, which generates a lowering of situational awareness, however bringing them to believe they had found the best formula to operate.
- The existence of adverse weather conditions, characterized by the presence of an extreme rainfall, which significantly reduced the overall visibility.
- The "black hole approach" phenomenon, due to adverse weather conditions together with an approach carried out at night, the sea, to a coast characterized by few dimly lit urban settlements.
This created the illusion in the PF of "feeling high" compared to what he saw and believed to be the threshold, with the result to get him to abandon the ideal descent profile, hitherto maintained, to make a correction and the subsequent short landing.
- The decrease of performance of the light beam produced by SLTH in extreme rain conditions; The only bright horizontal reference for the crew consisted of the crossbar of the SALS, probably mistaken for the threshold lights.
Final Report:

Crash of a Rockwell Aero Commander 500 in Santo Domingo

Date & Time: Sep 23, 2010 at 1245 LT
Registration:
N100PV
Flight Type:
Survivors:
Yes
Schedule:
San Juan - Santo Domingo
MSN:
500-784
YOM:
1959
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2500
Captain / Total hours on type:
100.00
Aircraft flight hours:
7810
Circumstances:
The twin engine aircraft departed San Juan-Isla Grande Airport on a private flight to Santo Domingo with two passengers and two pilots on board. On final approach to Santo Domingo-Las Américas-Dr. José Francisco Peña Gómez Airport, at an altitude of 2,000 feet and at a distance of 8 km from the airport, both engines failed simultaneously. As the crew realized he was unable to reach the airport, he attempted an emergency landing when the aircraft crashed in a dense wooded area located about one km southeast of runway 35 threshold. All four occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
Double engine failure on final approach due to fuel exhaustion. It was determined that prior to takeoff from San Juan Airport, the fuel quantity in the tanks was sufficient for the flight to Santo Domingo. But the fuel cap was missing prior to takeoff and the crew applied some 'duct tape' in an attempt to replace the fuel cap. Despite the aircraft was unworthy, the crew decided to takeoff in such conditions. Because the fuel cap was missing, some fuel leaked in flight, causing both engines to stop on final approach to Santo Domingo Airport.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in South Bimini

Date & Time: Sep 19, 2010 at 1440 LT
Operator:
Registration:
N84859
Survivors:
Yes
Schedule:
South Bimini - Fort Lauderdale
MSN:
31-7305043
YOM:
1973
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On September 19, 2010, at 1440 eastern daylight time, a Piper PA31-350, N84859, registered to Spirit Air Inc, and operated by Pioneer Air Service was on initial climb out when the lower half of the main cabin door came open. The pilot reversed his course and returned to the departure airport, landing on runway 27. The right main landing gear tire blew out on the landing roll. The airplane went off the right side of the runway, struck a tree, caught fire and came to a complete stop. Visual meteorological conditions prevailed and an instrument flight plan was filed. The commercial pilot and five passengers were not injured and the airplane received substantial damage. The flight originated from Bimini Airport, South Bimini Island, Bahamas, at 1435, and was operated in accordance with 14 Code of Federal Regulations Part 135.

Crash of an ATR42-320 in Puerto Ordaz: 17 killed

Date & Time: Sep 13, 2010 at 1023 LT
Type of aircraft:
Operator:
Registration:
YV1010
Survivors:
Yes
Schedule:
Porlamar - Puerto Ordaz
MSN:
371
YOM:
1994
Flight number:
VCV2350
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total hours on type:
1574.00
Copilot / Total flying hours:
1083
Copilot / Total hours on type:
483
Aircraft flight hours:
27085
Aircraft flight cycles:
29603
Circumstances:
Following two uneventful flights to Santiago Mariño and Maturín, the aircraft departed Porlamar on a flight to Puerto Ordaz with 47 passengers and a crew of four on board. While descending to Puerto Ordaz, at an altitude of 13,500 feet and at a distance of 79 km from the destination, the crew reported control difficulties. After being prioritized, the crew was instructed for an approach and landing on runway 07. At 1021LT, the crew reported his position at 3,000 feet and 28 km from the destination Airport. Two minutes later, the message 'mayday mayday mayday' was heard on the frequency. The aircraft went out of control and crashed in an industrial area located about 9 km short of runway, bursting into flames. Three crew members and 14 passengers were killed while 34 other occupants were injured, 10 seriously.
Probable cause:
The most probable cause for the occurrence of the accident was the malfunction of the centralized crew warning system (CCAS/CAC) with erroneous activation of the flight loss of lift warning system.
The following contributing factors were identified:
- Poor crew resources management,
- Loss of situational awareness,
- Inadequate coordination during the decision-making process to deal with abnormal situations in flight,
- Ignorance of the loss of lift warning system.
- Inadequate handling of flight controls.
Final Report:

Crash of a Boeing 747-44AF near Dubai: 2 killed

Date & Time: Sep 3, 2010 at 1941 LT
Type of aircraft:
Operator:
Registration:
N571UP
Flight Type:
Survivors:
No
Schedule:
Hong Kong - Dubai - Cologne
MSN:
35668/1393
YOM:
2007
Flight number:
UPS006
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
11410
Captain / Total hours on type:
367.00
Copilot / Total flying hours:
6130
Copilot / Total hours on type:
78
Aircraft flight hours:
9977
Aircraft flight cycles:
1764
Circumstances:
The four engine aircraft was completing a cargo flight from Hong Kong to Cologne with an intermediate stop in Dubai with two pilots on board. One minute after passing the BALUS waypoint, approaching the top of climb, as the aircraft was climbing to the selected cruise altitude of 32,000 feet, the Fire Warning Master Warning Light illuminated and the Audible Alarm [Fire Bell] sounded, warning the crew of a fire indication on the Main Deck Fire - Forward. The captain advised BAE-C that there was a fire indication on the main deck of the aircraft, informing Bahrain ATC that they needed to land as soon as possible. BAE-C advised that Doha International Airport (DOH) was at the aircraft’s 10 o’clock position 100 nm DME from the current location. The Captain elected to return to the point of departure, DXB. The crew changed the selected altitude from 32,000 feet to 28,000 feet as the aircraft changed heading back to DXB, the Auto Throttle [AT] began decreasing thrust to start the decent. The AP was manually disconnected, then reconnected , followed by the AP manually disconnecting for a short duration, the captain as handling pilot was manually flying the aircraft. Following the turn back and the activation of the fire suppression, for unknown reasons, the PACK 1 status indicated off line [PACKS 2 and 3 were off], in accordance with the fire arm switch activation. There was no corresponding discussion recorded on the CVR that the crew elected to switch off the remaining active PACK 1. As the crew followed the NNC Fire/Smoke/Fumes checklist and donned their supplemental oxygen masks, there is some cockpit confusion regarding the microphones and the intra-cockpit communication as the crew cannot hear the microphone transmissions in their respective headsets. The crew configured the aircraft for the return to DXB, the flight was in a descending turn to starboard onto the 095° reciprocal heading for DXB when the Captain requested an immediate descent to 10,000 ft. The reason for the immediate descent was never clarified in the available data. The AP was disengaged, the Captain then informed the FO that there was limited pitch control of the aircraft when flying manually. The Captain was manually making inputs to the elevators through the control column, with limited response from the aircraft. The flight was approximately 4 minutes into the emergency. The aircraft was turning and descending, the fire suppression has been initiated and there was a pitch control problem. The cockpit was filling with persistent continuous smoke and fumes and the crew had put the oxygen masks on. The penetration by smoke and fumes into the cockpit area occurred early into the emergency. The cockpit environment was overwhelmed by the volume of smoke. There are several mentions of the cockpit either filling with smoke or being continuously ‘full of smoke’, to the extent that the ability of the crew to safely operate the aircraft was impaired by the inability to view their surroundings. Due to smoke in the cockpit, from a continuous source near and contiguous with the cockpit area [probably through the supernumerary area and the ECS flight deck ducting], the crew could neither view the primary flight displays, essential communications panels or the view from the cockpit windows. The crew rest smoke detector activated at 15:15:15 and remained active for the duration of the flight. There is emergency oxygen located at the rear of the cockpit, in the supernumerary area and in the crew rest area. Due to the persistent smoke the Captain called for the opening of the smoke shutter, which stayed open for the duration of the flight. The smoke remained in the cockpit area. There was a discussion between the crew concerning inputting the DXB runway 12 Left [RWY12L] Instrument Landing System [ILS] data into the FMC. With this data in the FMC the crew can acquire the ILS for DXB RWY12L and configure the aircraft for an auto flight/auto land approach. The F.O. mentions on several occasions difficulty inputting the data based on the reduced visibility. However, the ILS was tuned to a frequency of 110.1 (The ILS frequency for DXB Runway 12L is 110.126), the Digital Flight Data Recorder [DFDR] data indicates that this was entered at 15:19:20 which correlates which the CVR discussion and timing. At approximately 15:20, during the emergency descent at around 21,000ft cabin pressure altitude, the Captain made a comment concerning the high temperature in the cockpit. This was followed almost immediately by the rapid onset of the failure of the Captain’s oxygen supply. Following the oxygen supply difficulties there was confusion regarding the location of the alternative supplementary oxygen supply location. The F.O either was not able to assist or did not know where the oxygen bottle was located; the Captain then gets out of the LH seat. This CVR excerpt indicates the following exchange between the Captain and F.O concerning the mask operation and the alternative oxygen supply bottle location. The exchange begins when the Captain’s oxygen supply stops abruptly with no other indications that the oxygen supply is low or failing. Based on the pathological information, the Captain lost consciousness due to toxic poisoning. After the Captain left the LH cockpit seat, the F.O. assumed the PF role. The F.O. remained in position as P.F. for the duration of the flight. There was no further interaction from the Captain or enquiry by the F.O as to the location of the Captain or the ability of the Captain to respond. The PF informed the BAE-C controllers that due to the limited visibility in the cockpit that it was not possible to change the radio frequency on the Audio Control Panel [ACP]. This visibility comment recurs frequently during the flight. The Bahrain East controller was communicating with the emergency aircraft via relays. Several were employed during the transition back to DXB. The aircraft was now out of effective VHF radio range with BAE-C. In order for the crew to communicate with BAE-C, BAE-C advised transiting aircraft that they would act as a communication relay between BAE-C and the emergency aircraft. BAE-C would then communicate to the UAE controllers managing the traffic in the Emirates FIR via a landline, who would then contact the destination aerodrome at Dubai, also by landline. The crew advised relay aircraft that they would stay on the Bahrain frequency as they could not see the ACP to change frequency. All of the 121.5 MHz transmissions by the PF were keyed via the VHF-R, all other radio communication with BAE-C and the relay aircraft are keyed from the VHF-L audio panel. There are several attempts by the UAE’s Area Control [EACC] to contact the flight on the guard frequency in conjunction with aircraft relaying information transmitting on the guard frequency to the accident flight. The PF of the accident flight does not appear to hear any of the transmissions from the air traffic control units or the relay aircraft on the guard frequency. Around this time, given the proximity of the aircraft to the RWY12L intermediate approach fix, Dubai ATC transmits several advisory messages to the flight on the Dubai frequencies, for example DXB ARR on 124.9 MHz advise that ‘Any runway is available’. The Runway lights for RWY30L were turned on to assist the return to DXB. The Aircraft condition inbound as the flight approached DXB for RWY12L. The computed airspeed was 350 knots, at an altitude of 9,000 feet and descending on a heading of 105° which was an interception heading for the ILS at RWY12L. The FMC was tuned for RWY12L, the PF selected the ‘Approach’ push button on the Mode Control Panel [MCP] the aircraft captures the Glide Slope (G/S). The AP did not transition into the Localizer Mode while the Localizer was armed. ATC, through the relay aircraft advised the PF, ‘you're too fast and too high can you make a 360? Further requesting the PF to perform a ‘360° turn if able’. The PF responded ‘Negative, negative, negative’ to the request. The landing gear lever was selected down at 15:38:00, followed approximately 20 seconds later by an the aural warning alarm indicating a new EICAS caution message, which based on the data is a Landing Gear Disagree Caution. At 15:38:20 the PF says: ‘I have no, uh gear’. Following the over flight of DXB, on passing north of the aerodrome abeam RWY12L. The last Radar contact before the flight passed into the zone of silence was at 15:39:03. The flight was on a heading of 89° at a speed of 320 knots , altitude 4200 feet and descending. The flight was cleared direct to Sharjah Airport (SHJ), SHJ was to the aircraft’s left at 10 nm, the SHJ runway is a parallel vector to RWY12L at DXB. The relay pilot asked the PF if it was possible to perform a left hand turn. This turn, if completed would have established the flight onto an approximate 10 mile final approach for SHJ RWY30. The flight was offered vectors to SHJ (left turn required) and accepts. The relay aircraft advised that SHJ was at 095° from the current position at 10 nm. The PF acknowledged the heading change to 095° for SHJ. For reasons undetermined the PF selected 195° degrees on the Mode Control Panel [MCP], the AP was manually disconnected at 15:40:05, the aircraft then banked to the right as the FMC captured the heading change, rolled wings level on the new heading, the throttles were then retarded, the aircraft entered a descending right hand turn at an altitude of 4000 feet, the speed gradually reduced to 240 kts. The PF made a series of pitch inputs which had a limited effect on the descent profile; the descent is arrested temporarily. There then followed a series of rapid pitch oscillations. These were not phugoid oscillations, these were commanded responses where the elevator effectiveness decreased rapidly as the airspeed decayed and the elevators could not compensate for the reduced thrust moment from the engines to maintain level flight in a steady state. This was due to the desynchronization of the control column inputs and the elevators. At this point had the aircraft remained on the current heading and descent profile it would have intercepted the terrain at or near a large urban conurbation, Dubai Silicone Oasis. The PF was in VHF communication with the relay aircraft requesting positional, speed and altitude information. From this point onwards, approximately 50 seconds elapse prior to the data ending. The effectiveness of the pitch control immediately prior to the end of the data was negligible. The control column was fully aft when the data ended, there was no corresponding elevator movement. The aircraft lost control in flight and made an uncontrolled descent into terrain.
Probable cause:
Probable causes:
- A large fire developed in palletized cargo on the main deck at or near pallet positions 4 or 5, in Fire Zone 3, consisting of consignments of mixed cargo including a significant number of lithium type batteries and other combustible materials. The fire escalated rapidly into a catastrophic uncontained fire.
- The large, uncontained cargo fire, that originated in the main cargo deck caused the cargo compartment liners to fail under combined thermal and mechanical loads.
- Heat from the fire resulted in the system/component failure or malfunction of the truss assemblies and control cables, directly affecting the control cable tension and elevator function required for the safe operation of the aircraft when in manual control.
- The uncontained cargo fire directly affected the independent critical systems necessary for crew survivability. Heat from the fire exposed the supplementary oxygen system to extreme thermal loading, sufficient to generate a failure. This resulted in the oxygen supply disruption leading to the abrupt failure of the Captain’s oxygen supply and the incapacitation of the captain.
- The progressive failure of the cargo compartment liner increased the area available for the smoke and fire penetration into the fuselage crown area.
- The rate and volume of the continuous toxic smoke, contiguous with the cockpit and supernumerary habitable area, resulted in inadequate visibility in the cockpit, obscuring the view of the primary flight displays, audio control panels and the view outside the cockpit which prevented all normal cockpit functioning.
- The shutdown of PACK 1 for unknown reasons resulted in loss of conditioned airflow to the upper deck causing the Electronic Equipment Cooling [EEC] system to reconfigure to “closed loop mode”. The absence of a positive pressure differential contributed to the hazardous quantities of smoke and fumes entering the cockpit and upper deck, simultaneously obscuring the crew’s view and creating a toxic environment.
- The fire detection methodology of detecting smoke sampling as an indicator of a fire is inadequate as pallet smoke masking can delay the time it takes for a smoke detection system to detect a fire originating within a cargo container or a pallet with a rain cover.
Contributing Factors:
- There is no regulatory FAA requirement in class E cargo compartments for active fire suppression.
- Freighter main deck class E fire suppression procedures which relay on venting airflow and depressurisation as the primary means of controlling a fire are not effective for large Class E cargo fires involving dangerous goods capable of Class D metal fire combustion.
- No risk assessment had been made for the failure of the cargo compartment liner based on the evolution of cargo logistics and associated cargo content fire threats, cargo hazards and bulk carriage of dangerous goods.
- The regulation standards for passive fire suppression do not adequately address the combined total thermal energy released by current cargo in a large cargo fire and the effect this has on the protection of critical systems.
- FAA and EASA regulatory requirements do not recognize the current total fire risk associated with pallets, pallet covers and containers as demonstrated by the NTSB/FAA testing.
- Class 9 Hazmat packing regulations do not address the total or potential fire risk that can result from lithium battery heat release during thermal runaway. Although non-bulk specification packaging is designed to contain leaks and protect the package from failure, the packaging for Class 9 does not function to contain thermal release.
- The growth rate of container and pallet fires after they become detectable by the aircraft’s smoke detection system can be extremely fast, precluding any mitigating action and resulting in an overwhelming total energy release and peak energy release rate for a standard fire load that cannot be contained.
- The course to return to Dubai required a series of complex radio communication relays due to the Pilot Flying’s inability to view and tune the radio transceivers.
- The relay communication between the Pilot Flying, relay aircraft and the various ATC stations resulted in communication confusion, incomplete and delayed communications, which contributed to the escalated workload and task saturation for the Pilot Flying.
- The Fire Main Deck non-normal checklist in the QRH was not fully completed by the crew or adhered to regarding the fire suppression flight level or land at nearest airport instruction.
- Task saturation due to smoke and multiple systems failures prevented effective use of the checklist by the crew.
- Communications between the ATCO units involved multiple stages of information exchange by landline and the destination aerodrome was not fully aware of the specific nature of the emergency, the difficulty that the Pilot Flying was experiencing or the assistance required.
- The Pilot Flying had not selected transponder code 7700, the emergency code, when radio communication with the destination aerodrome was not established.
Final Report: