Crash of an Airbus A330-202 in Tripoli: 103 killed

Date & Time: May 12, 2010 at 0601 LT
Type of aircraft:
Operator:
Registration:
5A-ONG
Survivors:
Yes
Schedule:
Johannesburg - Tripoli - London
MSN:
1024
YOM:
2009
Flight number:
AAW771
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
93
Pax fatalities:
Other fatalities:
Total fatalities:
103
Captain / Total flying hours:
17016
Captain / Total hours on type:
516.00
Copilot / Total flying hours:
4216
Copilot / Total hours on type:
516
Aircraft flight hours:
2175
Aircraft flight cycles:
572
Circumstances:
The aircraft was on a schedule flight from O. R. Tambo International Airport - Johannesburg (South Africa) to London, with an intermediate stop at Tripoli international Airport, Libya. The Aircraft took off on May 11th 2010 at 19:25 UTC as flight number 8U771/AAW771. There were three cockpit crew, eight cabin crew, and 93 passengers on board, with fifty thousand kg of fuel during takeoff role and the Aircraft mass was 187,501 kg. During final approach towards runway 09 at Tripoli international Airport, the crew announced go-around and initiated the miss approach procedure with the knowledge and confirmation of Tripoli tower. During the missed approach phase, the Aircraft responded to the crew’s inputs, velocity and altitude increased above the MDA, then the aircraft descended dramatically until collided with the ground about 1,200 meters from the threshold of the runway 09 and 150 meters to the right of its centerline, impact and post impact fire caused complete destruction to the Aircraft. A boy aged 8 was injured while 103 other occupants were killed.
Probable cause:
A final approach carried out in common managed guidance mode should have relieved the crew of their tasks. The limited coordination and cooperation between the two crew members, especially the change into vertical selected guidance mode by the PF, probably led to a lack of a common action plan. The lack of feedback from the 28 April 2010 flight, flown by the same crew on the same aircraft, did not allow them to anticipate the potential risks associated with managing non-precision approaches. The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined. During the go-around, the crew was surprised not to acquire visual references. On one hand the crew feared exceeding the aircraft’s speed limits in relation to its configuration, and on the other hand they were feeling the effects of somatogravic illusion due to the aircraft acceleration. This probably explains the aircraft handling inputs, mainly nose-down inputs, applied during the go-around. These inputs were not consistent with what is expected in this flight phase. The degraded CRM did not make it possible for either crew member to identify and recover from the situation before the collision with the ground, even when the TAWS warnings were activated close to the ground.
Based on elements from the investigation, the accident resulted from:
- The lack of common action plan during the approach and a final approach continued below the MDA, without ground visual reference acquired.
- The inappropriate application of flight control inputs during a go- around and on the activation of TAWS warnings,
- The lack of monitoring and controlling of the flight path.
These events can be explained by the following factors:
- Limited CRM on approach that degraded during the missed approach. This degradation was probably amplified by numerous radio-communications during the final approach and the crew’s state of fatigue,
- Aircraft control inputs typical in the occurrence of somatogravic perceptual illusions,
- Inappropriate systematic analysis of flight data and feedback mechanism within the AFRIQIYAH Airways.
- Non adherence to the company operation manual, SOP and standard terminology.
In addition, the investigation committee found the following as contributing factors to the accident:
- Weather available to the crew did not reflect the actual weather situation in the final approach segment at Tripoli International Airport.
- In adequacy of training received by the crew.
- Occupancy of tower frequency by both air and ground movements control.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Alert

Date & Time: May 10, 2010 at 1719 LT
Operator:
Registration:
C-FSJB
Survivors:
Yes
MSN:
377
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a supply mission in the Nunavut with three scientists on board. Equipped with ski, the aircraft landed on the snow covered terrain some 168 km north of Alert Air Base. After landing, the aircraft came to a halt when the right ski punctured the ice and the aircraft partially sunk while both engines were still running. All five occupants escaped uninjured and were evacuated two hours later by the crew of a Bell 407 to Resolute Bay. Damaged beyond repair, the aircraft was abandoned on site and later cancelled from registry in November 2011.
Probable cause:
Landing gear went through the ice after landing on ice/snow terrain.

Crash of a Lockheed C.3A Hercules in Brize Norton

Date & Time: May 6, 2010
Type of aircraft:
Operator:
Registration:
XV304
Flight Type:
Survivors:
Yes
Schedule:
Lyneham - Brize Norton
MSN:
4272
YOM:
1968
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a troop transfer mission between RAF Lyneham and Brize Norton. Following an uneventful flight, the four engine aircraft made a wheels up landing at Brize Norton Airport. It slid on the runway for few dozen metres before coming to rest. All four crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It appears that the crew failed to follow the approach checklist and forgot to lower the undercarriage. There was no reaction or any corrective action from the crew when the alarm sounded in the cockpit on approach, informing the crew that the undercarriage was not lowered. No technical anomalies were found on the aircraft or its equipment.

Crash of an Embraer ERJ-145LR in Mitú

Date & Time: May 5, 2010 at 1049 LT
Type of aircraft:
Operator:
Registration:
FAC-1173
Survivors:
Yes
Schedule:
Villavicencio - Mitú
MSN:
145-879
YOM:
2005
Flight number:
NSE9634
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10254
Captain / Total hours on type:
1060.00
Copilot / Total flying hours:
1061
Copilot / Total hours on type:
806
Aircraft flight hours:
9095
Circumstances:
After landing on runway 20 (1,760 meters long) at Mitú-Fabio Alberto León Bentley Airport, the aircraft encountered difficulties and was unable to stop within the remaining distance. It overran at a speed of 52 knots, went through a fence, lost its undercarriage and came to rest in a prairie some 163 metres further. All 41 occupants were uninjured while the aircraft was damaged beyond repair. It was registered FAC-1173 (military) and HK-4536 (civil).
Probable cause:
Wrong approach configuration on part of the crew. Execution of the landing procedure on runway 20 despite the fact that aircraft was unstable on approach. At runway threshold, the aircraft altitude was too high and its speed upon touchdown was excessive (132 knots). The airplane touched down 562 metres past the runway threshold, well beyond the touchdown zone. All brakes systems were activated but the upper right thrust reverser deployed and retracted shortly later due to technical reasons, which was considered as a contributory factor. The following factors also contributed to the mishap:
- Poor techniques used by the pilot-in-command on approach and after touchdown,
- Deviation from standard operating procedures (SOP),
- Non-adherence to published procedures,
- No reaction or corrective action to the EGPWS alarm.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in New Albany: 2 killed

Date & Time: May 2, 2010 at 2016 LT
Operator:
Registration:
N135CC
Flight Type:
Survivors:
No
Schedule:
Paducah – Louisville
MSN:
46-36192
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2494
Captain / Total hours on type:
14.00
Aircraft flight hours:
1396
Circumstances:
The instrument-rated pilot was issued a clearance to descend to 4,000 feet for radar vectors to a non precision instrument approach in instrument meteorological conditions (IMC). The last 1 minute 23 seconds of radar data indicated the airplane leveled at 4,000 feet for about 35 seconds and then varied between 3,800 feet and 3,900 feet for the remainder of the flight for which data was available. During this timeframe, the airspeed decreased from 131 knots to 57 knots. Witnesses observed the airplane descending in a spin, and one reported hearing the engine running. Recorded engine data showed an increase in engine power near stall speed, which was likely the pilot's response to the low airspeed. The airplane damage was consistent with a low-speed impact with some rotation about the airplane's vertical axis. The pilot did not make any transmissions to air traffic control indicating any abnormalities or emergency. Post accident examination of the airplane revealed no anomalies that would have precluded normal operation. During training on the accident airplane, the instructor recommended that the pilot get 25 to 50 hours of flight in visual meteorological conditions before flying in IMC in order to gain more familiarity with the radios, switches, and navigation equipment. The pilot only had 14 hours of flight time in the accident airplane before the accident flight, however it could not determined whether this played a role in the accident.
Probable cause:
The pilot’s failure to maintain airspeed in instrument meteorological conditions, which resulted in an aerodynamic stall.
Final Report:

Crash of a Beechcraft 200 Super King Air in Arlit

Date & Time: Apr 27, 2010 at 1830 LT
Operator:
Registration:
F-GLIF
Survivors:
Yes
Schedule:
Niamey - Arlit
MSN:
BB-192
YOM:
1977
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Arlit Airport, the crew lost visual contact with the runway due to a sand storm. The aircraft was too low and hit the ground short of runway. Upon impact, the undercarriage were torn off and the aircraft slid over few dozen metres before coming to rest. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The crew continued the approach in a reduced visibility due to blowing sand and descended too low without visual contact with the ground.

Crash of an Airbus A300B4-203F in Monterrey: 6 killed

Date & Time: Apr 13, 2010 at 2319 LT
Type of aircraft:
Operator:
Registration:
XA-TUE
Flight Type:
Survivors:
No
Schedule:
Mexico City - Monterrey - Los Angeles
MSN:
78
YOM:
1979
Flight number:
TNO302
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
16754
Captain / Total hours on type:
5446.00
Copilot / Total flying hours:
3114
Copilot / Total hours on type:
1994
Aircraft flight hours:
55170
Circumstances:
The aircraft departed Mexico City-Benito Juarez Airport on a cargo service to Los Angeles with an intermediate stop in Monterrey, carrying five crew members. On final approach to Monterrey-General Mariano Escobedo Airport by night, the crew encountered poor weather conditions with CB's and sky broken at 600 feet. On short final, while at a distance of 2 km from the runway threshold, the crew was cleared to land on runway 11. Shortly later, the aircraft rolled to the left then crashed on a motorway located 700 metres short of runway. The aircraft was totally destroyed and all five crew members were killed as well as one people in a car.
Probable cause:
The accident was the consequence of a loss of control following an unstable approach.
The following contributing factors were identified:
- Lack of crew coordination and crew resources management (CRM),
- Diminished situational awareness,
- Failure to follow proper operational procedures,
- Unstabilized non-precision approach,
- Unsuitable aircraft configuration,
- Adverse weather condition.
Final Report:

Crash of a Boeing 737-322 in Manokwari

Date & Time: Apr 13, 2010 at 1055 LT
Type of aircraft:
Operator:
Registration:
PK-MDE
Survivors:
Yes
Schedule:
Ujung Pandang - Sorong - Manokwari
MSN:
24660/1838
YOM:
1990
Flight number:
MZ836
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16450
Copilot / Total flying hours:
22139
Aircraft flight hours:
54759
Aircraft flight cycles:
38485
Circumstances:
On 13 April 2010, a Boeing B737-300 aircraft registered PK-MDE was being operated by PT. Merpati Nusantara Airline as a scheduled passenger flight MZ 836, from Hasanuddin Airport, Makassar, Sulawesi to Rendani Airport, Manokwari, Papua. It made a transit stop at Domine Eduard Osok Airport, Sorong, Papua. The aircraft departed from Makassar at 2010 UTC and landed at Sorong at 2214 UTC. The scheduled departure time from Sorong was 2235, but due to heavy rain over Manokwari, the departure was delayed for about two hours. The pilot in command was the pilot flying, and the copilot, who also held a command rating on the aircraft, was the support/monitoring pilot. The aircraft subsequently departed Sorong 2 hours and 43 minutes later, at 0118. The observed weather report issued by Badan Meteorologi dan Geofisika (BMG) Manokwari for takeoff and landing at 0100 indicated that the weather was “continuous slight rain, horizontal visibility of 3 to 4 kilometers, cloud overcast cumulus-stratocumulus, westerly wind at 5 knots”. The aircraft’s dispatch release from Sorong indicated that the flight was planned under the Instrument Flight Rules (IFR). The destination, Manokwari, had no published instrument approach procedure. Terminal area operations, including approach and landing, were required to be conducted under the Visual Flight Rules (VFR). At 0146 the crew made the first direct contact with Rendani Radio and reported their position as 14 Nm from Manokwari, and maintaining altitude 10,500 feet. Following this radio contact, Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals. The transcript of the Rendani Radio communications with the aircraft indicated that controller then instructed the crew to descend and joint right downwind for runway 35, and to report when overhead the airport. Shortly after, the crew reported overhead the airport at 5,000 feet. The controller then instructed the crew to report when they were on final approach for runway 35. The crew acknowledged this instruction. At 0154 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear. The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition. According to the Rendani Airport Administrator’s report to the investigation, the aircraft was observed to make a normal touchdown on the runway at about 0155, about 120 meters from the approach end of runway 35. The report stated that the aircraft’s engine reverser sound was not heard during landing roll. Witnesses on board the aircraft also stated that the aircraft made a smooth landing, and the engine reversers were not heard during the landing roll. During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. At about 0156 it came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River. The Observed Weather Report issued by BMG Manokwari for takeoff and landing at 0200 (4 minutes after the accident) indicated that the weather was continuous moderate rain, with a horizontal visibility of 4 kilometers, cloud overcast cumulus stratocumulus, south-westerly wind at 5 knots. The airport rescue and fire fighting unit was immediately deployed to assist the post crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation. The aircraft was substantially damaged. Nearby residents, police and armed forces personnel assisted the evacuation from the aircraft. The Rendani Airport Administrator reported that the passengers and crew members were evacuated and moved from the site by 0230. They were taken to the Manokwari General Hospital, and Manokwari Naval Hospital for further medical treatment.
Final Report:

Crash of a Tupolev TU-154M in Smolensk: 96 killed

Date & Time: Apr 10, 2010 at 1041 LT
Type of aircraft:
Operator:
Registration:
101
Flight Type:
Survivors:
No
Schedule:
Warsaw - Smolensk
MSN:
90A-837
YOM:
1990
Flight number:
PLF101
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
96
Captain / Total flying hours:
3531
Captain / Total hours on type:
2906.00
Copilot / Total flying hours:
1909
Copilot / Total hours on type:
475
Aircraft flight hours:
5142
Aircraft flight cycles:
3907
Circumstances:
On approach to Smolensk Airport in poor weather conditions, crew was forced to make a go-around and approach was abandoned three times. On the fourth approach, at a speed of 260 km/h, aircraft went beyond the minimum safe altitude, hit tree tops, lost its left wing and crashed in a huge explosion. All 96 occupants were killed, among them the President of the Polish Republic Lech Kaczyński and his wife. He was flying to Smolensk to take part to the commemoration of the 70th anniversary of Katyn massacre when Soviet Army killed 20,000 Polish officers. Among the delegation were also members of the Polish Senate and Government; the ex President, the vice-president of low Chamber, the Senate vice-president, the president of the polish central bank, the chief of military staff, the chief of ground forces, the chief of the Air Force, the chief of special forces, the chief of Marines, the personal assistant of President, the chief of National Security, the vice-Minister of Defense and the vice-Minister of Foreign Affairs.
Probable cause:
The immediate cause of the accident was the descent below the minimum descent altitude at an excessive rate of descent in weather conditions which prevented visual contact with the ground, as well as a delayed execution of the go-around procedure. Those circumstances led to an impact on a terrain obstacle resulting in separation of a part of the left wing with aileron and consequently to the loss of aircraft control and eventual ground impact.
Circumstances Contributing to the Accident:
1) Failure to monitor altitude by means of a pressure altimeter during a non-precision approach;
2) failure by the crew to respond to the PULL UP warning generated by the TAWS;
3) attempt to execute the go-around maneuver under the control of ABSU (automatic go-around)
4) Approach Control confirming to the crew the correct position of the airplane in relation to the RWY threshold, glide slope, and course which might have affirmed the crew's belief that the approach was proceeding correctly although the airplane was actually outside the permissible deviation margin;
5) failure by LZC to inform the crew about descending below the glide slope and delayed issuance of the level-out command;
6) incorrect training of the Tu-154M flight crews in the 36 Regiment.
Conducive circumstances
1) incorrect coordination of the crew's work, which placed an excessive burden on the aircraft commander in the final phase of the flight;
2) insufficient flight preparation of the crew;
3) the crew‘s insufficient knowledge of the airplane's systems and their limitations;
4) inadequate cross-monitoring among the crew members and failure to respond to the mistakes committed;
5) crew composition inadequate for the task;
6) ineffective immediate supervision of the 36 Regiment's flight training process by the Air Force Command;
7) failure by the 36 Regiment to develop procedures governing the crew's actions in the event of:
a) failure to meet the established approach criteria;
b) using radio altimeter for establishing alarm altitude values for various types of approach;
c) distribution of duties in a multi-crew flight.
8) sporadic performance of flight support duties by LZC over the last 12 months, in particular under difficult WC, and lack of practical experience as LZC at the SMOLENSK NORTH airfield.
Final Report:

Crash of a Learjet 25D in Bahías de Huatulco

Date & Time: Apr 1, 2010 at 1300 LT
Type of aircraft:
Operator:
Registration:
XA-UNC
Survivors:
Yes
Schedule:
Oaxaca – Bahías de Huatulco
MSN:
222
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Bahías de Huatulco Airport, the crew was unable to lower the landing gear. It was decided to perform a wheels up landing. The aircraft landed on its belly then slid for few dozen metres, veered off runway and came to rest, bursting into flames. All six occupants escaped uninjured but the aircraft was destroyed by fire. Among the passenger was Ulises Ruiz Ortiz, Governor of the State of Oaxaca.