Crash of an ATR72-212A in Manila

Date & Time: Jul 28, 2010 at 1515 LT
Type of aircraft:
Operator:
Registration:
RP-C7254
Survivors:
Yes
Schedule:
Tuguegarao – Manila
MSN:
828
YOM:
2008
Flight number:
5J509
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Cebu Pacific Air flight 5J509, an ATR 72-500, took off from Tuguegarao Airport, Philippines, bound for Manila-Ninoy Aquino International Airport. The first officer was the Pilot Flying (PF) while the captain was the Pilot Not Flying (PNF). Approaching Manila, the flight was under radar vector for a VOR/DME approach to runway 24. At 7 miles on finals the approach was stabilized. A sudden tailwind was experienced by the crew at 500 feet radio altitude (RA) which resulted in an increase in airspeed and vertical speed. The captain took over the controls and continued the approach. Suddenly, the visibility went to zero and consequently the aircraft experienced a bounced landing three times, before a go-around was initiated. During climb out the crew noticed cockpit instruments were affected including both transponders and landing gears. They requested for a priority landing and were vectored and cleared to land on runway 13. After landing the aircraft was taxied to F4 where normal deplaning was carried out. No injuries were reported on the crew and passengers.
Probable cause:
Primary Cause Factor:
- Failure of the flight crew to discontinue the approach when deteriorating weather and their associated hazards to flight operations had moved into the airport (Human Factor)
Contributory Factor:
- The adverse weather condition affected the judgment and decision-making of the PIC even prior to the approach to land. With poor weather conditions being encountered, the PIC still continued the approach and landing. (Environmental Factor)
Underlying Factor:
- As a result of the bounced landing, several cockpit instruments were affected including both transponders on board. One of the nosewheels was detached and all the landing gears could not be retracted. Further, the integrity of the structure may have been affected and chance airframe failure was imminent. With all of these conditions, the Captain still opted to request for a priority landing when emergency landing was needed.

Crash of an Airbus A321-231 in Islamabad: 152 killed

Date & Time: Jul 28, 2010 at 0941 LT
Type of aircraft:
Operator:
Registration:
AP-BJB
Survivors:
No
Site:
Schedule:
Karachi - Islamabad
MSN:
1218
YOM:
2000
Flight number:
ABQ202
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
146
Pax fatalities:
Other fatalities:
Total fatalities:
152
Captain / Total flying hours:
25497
Captain / Total hours on type:
1060.00
Copilot / Total flying hours:
1837
Copilot / Total hours on type:
286
Aircraft flight hours:
34018
Aircraft flight cycles:
13566
Circumstances:
Flight ABQ202, operated by Airblue, was scheduled to fly a domestic flight sector Karachi - Islamabad. The aircraft had 152 persons on board, including six crew members. The Captain of aircraft was Captain Pervez Iqbal Chaudhary. Mishap aircraft took-off from Karachi at 0241 UTC (0741 PST) for Islamabad. At time 0441:08, while executing a circling approach for RWY-12 at Islamabad, it flew into Margalla Hills, and crashed at a distance of 9.6 NM, on a radial 334 from Islamabad VOR. The aircraft was completely destroyed and all souls on board the aircraft, sustained fatal injuries.
Probable cause:
- Weather conditions indicated rain, poor visibility and low clouds in and around the airport. The information regarding prevalent weather and the required type of approach on arrival was in the knowledge of aircrew.
- Though aircrew Captain was fit to undertake the flight on the mishap day, yet his portrayed behavior and efficiency was observed to have deteriorated with the inclement weather at BBIAP Islamabad.
- The chain of events leading to the accident in fact started with the commencement of flight, where Captain was heard to be confusing BBIAP Islamabad with JIAP Karachi while planning FMS, and Khanpur Lake (Wah) with Kahuta area during holding pattern. This state continued when Captain of the mishap flight violated the prescribed Circling Approach procedure for RWY-12; by descending below MDA (i.e 2,300 ft instead of maintaining 2,510 ft), losing visual contact with the airfield and instead resorting to fly the non-standard self created PBD based approach, thus transgressing out of protected airspace of maximum of 4.3 NM into Margallas and finally collided with the hills.
- Aircrew Captain not only clearly violated the prescribed procedures for circling approach but also did not at all adhere to FCOM procedures of displaying reaction / response to timely and continuous terrain and pull up warnings (21 times in 70 seconds) – despite these very loud, continuous and executive commands, the Captain failed to register the urgency of the situation and did not respond in kind (break off / pull off).
- F/O simply remained a passive bystander in the cockpit and did not participate as an effective team member failing to supplement / compliment or to correct the errors of his captain assertively in line with the teachings of CRM due to Captain’s behavior in the flight.
- At the crucial juncture both the ATC and the Radar controllers were preoccupied with bad weather and the traffic; the air traffic controller having lost visual contact with the aircraft got worried and sought Radar help on the land line (the ATC does not have a Radar scope); the radar controller having cleared aircraft to change frequency to ATC, got busy with the following traffic. Having been alerted by the ATC, the Radar controller shifted focus to the mishap aircraft – seeing the aircraft very close to NFZ he asked the ATCO (on land line) to ask the aircraft to immediately turn left, which was transmitted. Sensing the gravity of the situation and on seeing the aircraft still heading towards the hills, the Radar controller asked the ATCO on land line “Confirm he has visual contact with the ground. If not, then ask him to immediately climb, and make him execute missed approach”. The ATCO in quick succession asked the Captain if he had contact with the
airfield – on receiving no reply from aircrew the ATCO on Radars prompting asked if he had contact with the ground. Aircrew announced visual contact with the ground which put ATS at ease.
Ensuing discussion and mutual situational update (on land line) continued and, in fact, the ATC call “message from Radar immediately turn left” was though transmitted, but by the time the call got transmitted, the aircraft had crashed at the same time.
- The accident was primarily caused by the aircrew who violated all established procedures for a visual approach for RWY-12 and ignored several calls by ATS Controllers and EGPWS system warnings (21) related to approaching rising terrain and PULL UP.
Final Report:

Crash of a Boeing 737-7L9 in Conakry

Date & Time: Jul 28, 2010 at 0130 LT
Type of aircraft:
Operator:
Registration:
TS-IEA
Survivors:
Yes
Schedule:
Nouakchott - Dakar - Conakry
MSN:
28014/766
YOM:
2001
Flight number:
MTW620
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
91
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Nouakchott in he evening of July 27 on a regular schedule service to Conakry with an intermediate stop in Dakar, carrying 91 passengers and a crew of six. Following an uneventful flight from Dakar, the crew started a night approach to Conakry-Gbessia Airport. After touchdown on a wet runway (due to recent rain falls), the aircraft was unable to stop within the remaining distance. It overran, collided with the ILS antenna and some approach lights, lost its nose gear and came to rest 500 metres further. Ten passengers were injured while all 87 other occupants escaped unhurt. The aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew, causing the aircraft to land half way down the runway and reducing the landing distance available. The crew failed to follow SOP's and to initiate a go-around procedure as the landing was obviously missed.

Crash of an Antonov AN-12BP at Camp Dwyer AFB

Date & Time: Jul 28, 2010
Type of aircraft:
Operator:
Registration:
3X-GEQ
Flight Type:
Survivors:
Yes
MSN:
4 3 422 10
YOM:
1964
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Camp Dwyer AFB (Forward Operating Base Dwyer) located in the Helmand Province, the aircraft went out of control, veered off runway, collided with a fence and came to rest into a ravine, broken in two. All six occupants were uninjured while the aircraft was damaged beyond repair. It was later dismantled by the US Air Force. The aircraft was carrying a load of fresh fruits and dairy products.

Crash of a Raytheon 390 Premier I in Oshkosh

Date & Time: Jul 27, 2010 at 1816 LT
Type of aircraft:
Operator:
Registration:
N6JR
Flight Type:
Survivors:
Yes
Schedule:
Detroit - Oshkosh
MSN:
RB-161
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9095
Captain / Total hours on type:
1406.00
Aircraft flight hours:
1265
Aircraft flight cycles:
930
Circumstances:
The accident occurred during the Experimental Aircraft Association’s Airventure 2010 fly-in convention. Because of the high density of aircraft operations during the fly-in, the Federal Aviation Administration implemented special air traffic control procedures to accommodate traffic demand and maximize runway capacity. Arriving aircraft were issued landing instructions and clearances by a tower controller using a specified tower radio frequency. Departing aircraft were handled by another team of controllers operating on a separate radio frequency that was associated with a mobile operations unit located near the runway. Air traffic control data indicated that the accident airplane established contact with the tower controller and entered a left traffic pattern for runway 18R. As the accident airplane was turning from downwind to base leg, the controller handling departures cleared a Piper Cub for an immediate takeoff and angled departure (a procedure used by slower aircraft to clear the runway immediately after liftoff by turning across the runway edge). The accident pilot was not monitoring the departure frequency, and, therefore, he did not hear the radio transmissions indicating that the departing Piper Cub was going to offset to the left of the runway after liftoff. The accident pilot reported that, while on base leg, he became concerned that his descent path to the runway would conflict with the Piper Cub that was on takeoff roll. He stated that he overshot the runway centerline during his turn from base to final, and, when he completed the turn, his airplane was offset to the right of the runway. The pilot stated that, at this point, he decided not to land because of a perceived conflict with the departing Piper Cub that was ahead and to the left of his position. The pilot reported that he initiated a go-around, increasing engine power slightly, but not to takeoff power, as he looked for additional traffic to avoid. He estimated that he advanced the throttle levers "probably a third of the way to the stop," and, as he looked for traffic, the stall warning stick-shaker and stick-pusher systems activated almost simultaneously as the right wing stalled. The airplane subsequently collided with terrain in a nose down, right wing low attitude. A postaccident review of available air traffic control communications, amateur video of the accident sequence, controller and witness statements, and position data recovered from the accident airplane indicated that the Piper Cub was already airborne, had turned left, and was clear of runway 18R when the accident airplane turned from base to final. The postaccident examination did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. The airplane flight manual states that, in the event of a go-around, the pilot should first advance engine thrust to takeoff power and then establish Vref (reference landing approach speed). The pilot's decision not to select takeoff power during the go-around directly contributed to the development of the aerodynamic stall at a low altitude.
Probable cause:
The pilot's decision not to advance the engines to takeoff power during the go-around, as stipulated by the airplane flight manual, which resulted in an aerodynamic stall at a low altitude.
Final Report:

Crash of a McDonnell Douglas MD-11F in Riyadh

Date & Time: Jul 27, 2010 at 1138 LT
Type of aircraft:
Operator:
Registration:
D-ALCQ
Flight Type:
Survivors:
Yes
Schedule:
Frankfurt - Riyadh
MSN:
48431/534
YOM:
1993
Flight number:
LH8460
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8270
Captain / Total hours on type:
4466.00
Copilot / Total flying hours:
3444
Copilot / Total hours on type:
219
Aircraft flight hours:
73247
Aircraft flight cycles:
10073
Circumstances:
The airplane operated on Flight LH8460, a scheduled cargo service operating from Frankfurt (FRA) to Riyadh (RUH). It carried 80 tons of cargo. The accident flight departed Frankfurt about 05:16 local time (03:16 UTC), 2.5 hours later than originally scheduled due to minor maintenance issues. The accident flight was the first time the captain and first officer had flown together. The captain decided that the first officer, who had been employed with Lufthansa Cargo for 7 months and had not flown into Riyadh before, would fly the leg because he believed it would be an easy leg appropriate for the first officer. Cruise flight and approach to Riyadh were uneventful. The first officer indicated that he completed the approach briefing about 25 minutes before landing, calculating that he would use a flap setting of 35°, target 72 percent N1 rpm on final approach, expect a pitch attitude of about 4.5° on final approach, and commence the flare about 40 feet above ground level (agl). The flight was radar vectored to the instrument landing system of runway 33L, and the first officer flew the approach with a planned Vref of 158 knots. Convective conditions prevailed, with a temperature of 39°C and winds at 15 to 25 knots on a heading closely aligned with the landing runway. The aircraft was centered on the glide slope and localizer during the approach, until 25 seconds before touchdown when it dipped by half a dot below the glide slope. During that period, the indicated airspeed oscillated between 160 and 170 kt, centered about 166 kt. The ground speed was 164 kt until 20 sec. prior to touchdown, when it began to increase and reached 176 kt at touchdown. The flare was initiated by the first officer between 1.7 and 2.0 sec. before touchdown, that is: 23 to 31 feet above the runway. The main gear touchdown took place at 945 ft from the runway threshold at a descent rate of -13 ft/sec. (780 ft/min) resulting in a normal load factor of 2.1g. The aircraft bounced with the main gear reaching a maximum height of 4ft above the runway with the spoilers deployed to 30 degrees following main-wheel spin up. During this bounce, the captain who was the Pilot Monitoring (PM) pushed on the control column resulting in an unloading of the aircraft. The aircraft touched down a second time in a flat pitch attitude with both the main gear and nose gear contacting the runway, at a descent rate of -11 ft/sec. (660 ft/min), achieving a load factor of 3.0g. Just prior to this second touchdown, both pilots pulled on the control column, which combined with the rebound of the nose gear from the runway, resulted in a 14° pitch angle during the second bounce. Additionally, the spoilers reached their full extension of 60° following the compression of the nose gear strut during the second touchdown. During this second bounce, the main gear reached a height of 12 ft above the runway. Early in this second bounce, the captain pushed the control column to its forward limit and the elevators responded accordingly. Prior to the third and final touchdown, both pilots pulled back on the control column at slightly different times. Although the elevators responded accordingly and started to reduce the nose-down pitch rate, the aircraft was still pitching down at the third touchdown. During this third touchdown, the aircraft contacted the runway at a descent rate of -17 ft/sec (1020 ft/min), thus achieving a load factor of 4.4g. At this point, the aft fuselage ruptured behind the wing trailing edge. Two fuel lines were severed and fuel spilled within the left hand wheel well. A fire ignited and travelled to the upper cargo area. The captain attempted to maintain control of the aircraft within the runway boundaries. Not knowing about the aft fuselage being ruptured and dragging on the runway, the captain deployed the engine thrust reversers, but only the no. 1 and the no. 3 engines responded. The captain maintained directional control of the aircraft as best he could and requested the First Officer to declare a Mayday. The aircraft then went towards the left side of the runway as the captain attempted, without success, to maintain the aircraft on the runway. As the aircraft departed the runway, the nose gear collapsed and the aircraft came to a full stop 8800 ft from the threshold of the runway and 300 ft left from the runway centerline. The fuel to the engines was cut off and both pilots evacuated the aircraft by using the slide at the Left One (L1) door. The mid portion of the aircraft was on fire.
Probable cause:
Cause Related Findings:
1. The flight crew did not recognize the increasing sink rate on short final.
2. The First officer delayed the flare prior to the initial touchdown, thus resulting in a bounce.
3. The flight crew did not recognize the bounce.
4. The Captain attempted to take control of the aircraft without alerting the First Officer resulting in both flight crews acting simultaneously on the control column.
5. During the first bounce, the captain made an inappropriate, large nose-down column input that resulted in the second bounce and a hard landing in a flat pitch attitude.
6. The flight crew responded to the bounces by using exaggerated control inputs.
7. The company bounced-landing procedure was not applied by the flight crew.
Final Report:

Crash of a Fokker F27 Friendship 600 in Lubumbashi

Date & Time: Jul 20, 2010
Type of aircraft:
Operator:
Registration:
9Q-CJV
Survivors:
Yes
MSN:
10430
YOM:
1970
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing, one of the main landing gear collapsed. The aircraft slid for few dozen metres before coming to rest on the runway. All occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Failure of a landing gear upon landing for unknown reasons.

Crash of a Comp Air CA-8 in Mount Pleasant: 1 killed

Date & Time: Jul 19, 2010 at 1400 LT
Type of aircraft:
Operator:
Registration:
N882X
Flight Type:
Survivors:
No
Schedule:
Merritt Island - Mount Pleasant
MSN:
0281020
YOM:
2003
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1927
Captain / Total hours on type:
5.00
Aircraft flight hours:
150
Circumstances:
The pilot was conducting the first leg of a positioning flight in an experimental, amateur built, tail-wheel turboprop airplane. During landing, the airplane touched down to the right of the runway centerline and departed the right side of the runway. The pilot then added engine power to attempt an aborted landing. The airplane lifted off the runway, pitched up at a steep angle, stalled, and impacted the ground. Examination of the wreckage did not reveal any mechanical malfunctions; however, a postcrash fire consumed the majority of the wreckage. The airplane's pitch trim actuator was observed in the landing position, which was the full nose-up position and would have resulted in a steep nose-up attitude during climb-out, if not corrected by the pilot. The pilot had accumulated about 1,930 hours of total flight experience; however, he only had 5 total hours in the same make and model as the accident airplane.
Probable cause:
The pilot's failure to retrim the airplane and maintain aircraft control during an aborted landing, which resulted in an inadvertent stall. Contributing to the accident was the pilot's lack of experience in the accident airplane make and model.
Final Report:

Crash of a Cessna 550 Citation Bravo in Brač

Date & Time: Jul 15, 2010 at 1646 LT
Type of aircraft:
Operator:
Registration:
YU-BSG
Survivors:
Yes
Schedule:
Tirana – Brač
MSN:
550-1049
YOM:
2003
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
3427
Aircraft flight cycles:
2661
Circumstances:
Following an uneventful flight from Tirana, the crew started the approach to Brač Airport in good weather conditions. After landing on runway 04, the crew started the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, went through a fence, lost its undercarriage and came to rest in a rocky area, bursting into flames. All five occupants escaped uninjured while the aircraft was partially destroyed by a post crash fire.
Probable cause:
Wrong approach configuration on part of the crew who landed too far down the runway, reducing the landing distance available. The following contributing factors were identified:
- Excessive speed on approach (the IAS was 143 knots upon touchdown),
- The crew completed the approach in a too steep descent,
- Incorrect flare which caused the aircraft to land too dar down the runway,
- Insufficient landing distance available,
- The crew failed to initiate a go-around procedure.
Final Report:

Crash of a Cessna 421A Golden I Eagle in Tulsa: 3 killed

Date & Time: Jul 10, 2010 at 2205 LT
Type of aircraft:
Operator:
Registration:
N88DF
Flight Type:
Survivors:
No
Schedule:
Pontiac – Tulsa
MSN:
421A-0084
YOM:
1968
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
592
Captain / Total hours on type:
67.00
Aircraft flight hours:
640
Circumstances:
During the 3.5-hour flight preceding the accident flight, the airplane used about 156 gallons of the 196 gallons of usable fuel. After landing, the airplane was topped off with 156 gallons of fuel for the return flight. During the preflight inspection, a line serviceman at the fixed based operator observed the right main fuel tank sump become stuck in the open position. He estimated 5 to 6 gallons of fuel were lost before the sump seal was regained, but the exact amount of fuel lost could not be determined. The lost fuel was not replaced before the airplane departed. Data from an on board GPS unit indicate that the airplane flew the return leg at an altitude of about 4,500 feet mean sea level for about 4 hours. About 4 minutes after beginning the descent to the destination airport, the pilot requested to divert to a closer airport. The pilot was cleared for an approach to runway 18R at the new destination. While on approach to land, the pilot reported to the air traffic control tower controller, “we exhausted fuel.” The airplane descended and crashed into a forested area about 1/2 mile from the airport. Post accident examination of the right and left propellers noted no leading edge impact damage or signatures indicative of rotation at the time of impact. Examination of the airplane wreckage and engines found no malfunctions or failures that would have precluded normal operation. The pilot did not report any problems with the airplane or its fuel state before announcing the fuel was exhausted. His acceptance of the approach to runway 18R resulted in the airplane flying at least 1 mile further than if he had requested to land on runway 18L instead. If the pilot had declared an emergency and made an immediate approach to the closest runway when he realized the exhausted fuel state, he likely would have reached the airport. Toxicological testing revealed cyclobenzaprine and diphenhydramine in the pilot’s system at or above therapeutic levels. Both medications carry warnings that use may impair mental and/or physical abilities required for activities such as driving or operating heavy machinery. The airplane would have used about 186 gallons of fuel on the 4-hour return flight if the engines burned fuel at the same rate as the previous flight. The fuel lost during the preflight inspection and the additional 30 minutes of flight time on the return leg reduced the airplane’s usable fuel available to complete the planned flight, and the pilot likely did not recognize the low fuel state before the fuel was exhausted due to impairment by the medications he was taking.
Probable cause:
The pilot’s inadequate preflight fuel planning and management in-flight, which resulted in total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s use of performance-impairing medications.
Final Report: