Takeoff (climb)

Flight Type:

Humanitarian

Survivors:

Site:

Democratic Republic of Congo

Schedule:

Kamonia – Kamako

MSN:

208B-2386

YOM:

2012

Flight number:

UNO212H

Location:

Kamonia

Kasai-Occidental

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3668

Captain / Total hours on type:

3385.00

Copilot / Total flying hours:

1373

Copilot / Total hours on type:

970

Circumstances:

The single engine aircraft departed Kamonia on a special flight to Kamako on behalf of the United Nations Humanitarian Air Service (UNHAS), carrying three passengers and two pilots. During the takeoff roll from runway 34, the pilot-in-command started the rotation but the aircraft encountered difficulties to gain height. The nose gear and the cargo pod impacted an embankment located at the end of the runway and the aircraft flipped over and came to rest upside down. All five occupants escaped with minor injuries and the aircraft was destroyed.

Probable cause:

It was determined that the aircraft failed to gain sufficient speed during the last portion of the runway due to an excessive accumulation of sand on the ground. The pilot-in-command elected to rotate when the aircraft impacted terrain.
The two following factors were identified:
- The pilot's ability to make a timely decision,
- Lack of coordination between the two CRM (standard call out) pilots during takeoff manoeuvres.

Final Report:

Crash of a Boeing 737-201 in Havana: 112 killed

Date & Time: May 18, 2018 at 1210 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

XA-UHZ

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Havana-José Martí (Rancho Boyeros)

Schedule:

Havana – Holguín

MSN:

21816/592

YOM:

1979

Flight number:

DMJ972

Location:

La Habana

Country:

Cuba

Region:

Central America

Crew on board:

Crew fatalities:

Pax on board:

107

Pax fatalities:

Other fatalities:

Total fatalities:

112

Captain / Total flying hours:

16655

Copilot / Total flying hours:

2314

Aircraft flight hours:

69596

Aircraft flight cycles:

70651

Circumstances:

After takeoff from runway 06 at Havana-José Martí Airport, while in initial climb, the undercarriage were raised when the aircraft entered an excessive nose-up angle of 30°. It rolled to the right then descended until it struck power cables and a railway track before it disintegrated in a field located less than one km east from the airport. Three female passengers were seriously injured while 110 other occupants were killed, among them 102 Cubans, 6 Mexicans (crew) and 2 Argentinians. Three days after the accident, one of the three survivors died from her injuries. A second survivor died one week later, on May 25. The aircraft was operated by Cubana de Aviacíon under a wet lease contract from the Mexican operator Global Air (Damojh Aéreolíneas), and the service was operated under callsign DMJ972.

Probable cause:

Loss of control of the aircraft during initial climb following a chain of human errors in the preparation of the flight and the weight and balance calculation. It was determined that the crew calculated the CofG to be 17,4% while it was actually 28,5%, about 0,5% below the rear limit of 29%. Consequently, the horizontal stabilizer trim was set at 5 3/4 units instead of 3 1/4 units. This caused the aircraft to enter an excessive nose up attitude immediately after liftoff.
The following contributing factors were identified:
- Inconsistencies in crew training,
- Errors in weight and balance calculations,
- Low operational standards manifested in flight.

Final Report:

Crash of a Lockheed WC-130H Hercules in Savannah: 9 killed

Date & Time: May 2, 2018 at 1127 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

65-0968

Flight Phase:

Flight Type:

Military

Survivors:

Site:

Libyan Air Force - Al Quwwat Al-Jawwiya Al Libiyya

Schedule:

Savannah – Davis-Monthan

MSN:

4110

YOM:

1965

Location:

Savannah

Georgia

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total hours on type:

2070.00

Copilot / Total hours on type:

Circumstances:

On 2 May 2018, at approximately 1127 hours local time (L), the Mishap Aircraft (MA), a WC-130H, tail number 65-0968, assigned to the Puerto Rico Air National Guard, 156th Airlift Wing (156 AW), located at Muñiz Air National Guard Base, Puerto Rico, crashed approximately 1.5 miles northeast of Savannah/Hilton Head International Airport (KSAV), Georgia. All nine members aboard the MA—Mishap Pilot 1 (MP1), Mishap Pilot 2, Mishap Navigator, Mishap Flight Engineer, and Mishap Loadmaster (collectively the “Mishap Crew (MC)”), and four mission essential personnel, Mishap Airman 1, 2, 3, and 4—perished during the accident. The MC’s mission was to fly the MA to the 309th Aerospace Maintenance and Regeneration Group at Davis-Monthan Air Force Base, Arizona (commonly referred to as the “Boneyard”), for removal from service. The MA had been at KSAV for almost a month, since 9 April 2018, to undergo prescheduled fuel cell maintenance and unscheduled work on engine number one by 156 AW maintenance personnel using the facilities of the 165th Airlift Wing. During takeoff roll, engine one revolutions per minute (RPM) fluctuated and did not provide normal RPM when MP1 advanced the throttle lever into the flight range for takeoff. Approximately eight seconds prior to aircraft rotation, engine one RPM and torque significantly decayed, which substantially lowered thrust. The fluctuation on roll and significant performance decay went unrecognized by the MC until rotation, when MP1 commented on aircraft control challenges and the MA veered left and nearly departed the runway into the grass before it achieved flight. The MA departed KSAV at approximately 1125L. As the MC retracted the landing gear, they identified the engine one RPM and torque malfunction and MP1 called for engine shutdown. However, the MC failed to complete the Takeoff Continued After Engine Failure procedure, the Engine Shutdown procedure, and the After Takeoff checklist as directed by the Flight Manual, and the MA’s flaps remained at 50 percent. Additionally, MP1 banked left into the inoperative engine, continued to climb, and varied left and right rudder inputs. At an altitude of approximately 900 feet mean sea level and 131 knots indicated air speed, MP1 input over nine degrees of left rudder, the MA skidded left, the left wing stalled, and the MA departed controlled flight and impacted the terrain on Georgia State Highway 21.

Probable cause:

The board president found, by a preponderance of the evidence, the cause of the mishap was MP1’s improper application of left rudder, which resulted in a subsequent skid below three-engine minimum controllable airspeed, a left-wing stall, and the MA’s departure from controlled flight. Additionally, the board president found, by a preponderance of the evidence, the MC’s failure to adequately prepare for emergency actions, the MC’s failure to reject the takeoff, the MC’s failure to properly execute appropriate after takeoff and engine shutdown checklists and procedures, and the Mishap Maintainers’ failure to properly diagnose and repair engine number one substantially contributed to the mishap.

Final Report:

Crash of a Lockheed C-130 Hercules in Sharara: 3 killed

Date & Time: Apr 29, 2018 at 1225 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

111

Flight Phase:

Flight Type:

Military

Survivors:

Site:

Wadi al Hayaa (وادي الحياة)

Schedule:

Sharara - Mitiga

MSN:

4992

YOM:

1984

Location:

Sharara Field

Country:

Libya

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

National Oil Corporation confirms a C-130 aircraft chartered by Akakus Oil crashed during take-off, 2 km from the Sharara oil field, after delivering 18 tonnes of catering and maintenance supplies. The crash occurred at 12:25pm on Sunday, April 29, 2018. Firefighters and paramedics quickly rushed to the scene. The tragic incident resulted in the death of three crew members and the injury of one other who is being evacuated by air to receive medical treatment in Tripoli. The NOC Board of Directors cancelled all their commitments and are presently at Akakus headquarters meeting with local management and a number of emergency staff to follow up on this tragic incident. The circumstances of the crash are still being investigated. Mr. Fayez Al-Sarraj, Chairman of the Presidential Council, was briefed on the developments of the incident, and expressed his solidarity with the families of the victims, ordering the preparation of a decree commemorating the deceased as martyrs. The General Civil Aviation Authority (GCAA) was also briefed and offered its condolences to the Chief of Staff of the Air Force. The plane in question is the property of the Libyan Air Force but was chartered by Akakus Oil, who operate the Sharara field. The company was forced to charter the aircraft due to road closures and the security situation on the ground stemming from a road blockade leading to the field.

Crash of an Ilyushin II-76TD at Boufarik AFB: 257 killed

Date & Time: Apr 11, 2018 at 0750 LT

Type of aircraft:

Ilyushin II-76

Operator:

Registration:

7T-WIV

Flight Phase:

Flight Type:

Military

Survivors:

Site:

Schedule:

Boufarik – Béchar – Tindouf

MSN:

1043419649

YOM:

1994

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

247

Pax fatalities:

Other fatalities:

Total fatalities:

257

Circumstances:

The aircraft was engaged in a troop transport from Boufarik to Tindouf with an intermediate stop in Béchar, west Algeria, and was carrying 247 soldiers and their family members and 10 crew members. Shortly after takeoff from the Boufarik AFB located some 25 km southwest of Algiers, while climbing to a height of about 150 meters, the aircraft entered an uncontrolled descent and crashed in an agricultural zone located near the airport, bursting into flames. The airplane was totally destroyed by impact forces and a post crash fire. It was quickly confirmed by the Algerian Authorities that none of the 257 occupants survived the crash, among them 26 members of the Front Polisario. According to first testimonies, it appears that the left wing (engine?) was on fire when control was lost.

Crash of a Piper PA-31P Pressurized Navajo in Laredo: 2 killed

Date & Time: Mar 8, 2018 at 1038 LT

Type of aircraft:

Piper PA-31-310 Navajo

Operator:

Robert R. Marshall

Registration:

N82605

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Schedule:

Laredo - Laredo

MSN:

31P-7730010

YOM:

1977

Location:

Laredo

Texas

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4243

Copilot / Total flying hours:

194

Aircraft flight hours:

3185

Circumstances:

The commercial pilot and passenger, who held a student certificate, departed runway 18R for a local flight in a multi-engine airplane. The pilot held a flight instructor certificate for single-engine airplane. Just after takeoff, the tower controller reported to the pilot that smoke was coming from the left side of the airplane. The pilot acknowledged, stating that they were going to "fix it," and then entered a left downwind for runway 18R, adding that they didn't need any assistance. The controller subsequently cleared the airplane to land on runway 18L, which the pilot acknowledged. Two witnesses reported seeing the smoke come from the left engine. Still images taken from airport security video show the airplane before making the turn to land with white smoke trailing and the landing gear down. The airplane was then seen in a steep left turn to final approach exceeding 90° of bank, before it impacted terrain, just short of the runway in a near vertical attitude. A postcrash fire ensued. The examination of the wreckage found that the left engine's propeller was not being driven by the engine at the time of impact. The left propeller was not in the feathered position and the landing gear was found extended. The damage to the right engine propeller blades was consistent with the engine operating at high power at impact. The examination of the airframe and engines revealed no evidence of preimpact anomalies; however, the examinations were limited by impact and fire damage which precluded examination of the hoses and lines associated with the engines. The white smoke observed from the left side of the airplane was likely the result of an oil leak which allowed oil to reach the hot exterior surfaces of the engine; however, this could not be verified due to damage to the engine. There was no evidence of oil starvation for either engine. Both the extended landing gear and non-feathered left propeller would have increased the drag on the airplane. Because the pilot's operating procedures for an engine failure in a climb call for feathering the affected engine and raising the landing gear until certain of making the field, it is unlikely the pilot followed the applicable checklists in response to the situation. Further, the change from landing on runway 18R to 18L also reduced the radius of the turn and increased the required angle of bank. The increased left banked turn, the right engine operating at a high-power setting, and the airplane's increased drag likely decreased the airplane airspeed below the airplane's minimum controllable airspeed (Vmc), which resulted in a loss of control.

Probable cause:

An engine malfunction for undetermined reasons and the subsequent loss of control, due to the pilot's improper decision to maneuver the airplane below minimum controllable airspeed and his improper response to the loss of engine power.

Final Report:

Crash of a Beechcraft B100 King Air in Abbotsford

Date & Time: Feb 23, 2018 at 1204 LT

Type of aircraft:

Beechcraft 100 King Air

Operator:

Registration:

C-GIAE

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Abbotsford - San Bernardino

MSN:

BE-8

YOM:

1976

Flight number:

IAX640

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

10000

Captain / Total hours on type:

800.00

Aircraft flight hours:

10580

Circumstances:

Weather conditions at Abbotsford at the time of departure consisted of a temperature of -2°C in moderate to heavy snowfall with winds of approximately 10 knots. Prior to the departure, the fuel tanks were filled to capacity and the pilot and passengers boarded the aircraft inside the operator's heated hangar. The aircraft was towed outside of the hangar without being treated with anti-ice fluid, and taxied for the departure on runway 07. Due to an inbound arrival at Abbotsford, C-GIAE was delayed for departure. Once cleared for takeoff, the aircraft had been exposed to snow and freezing conditions for approximately 14 minutes. After becoming airborne, the aircraft experienced power and control issues shortly after the landing gear was retracted. The aircraft collided with terrain within the airport perimeter. Four passengers and the pilot sustained serious injuries as a result of the accident which destroyed the aircraft.

Probable cause:

The accident was the consequence of the combination of the following findings:
- The occurrence aircraft exited a warm hangar and was exposed to 14 minutes of heavy snow in below-freezing conditions. This resulted in a condition highly conducive to severe ground icing,
- As the aircraft climbed out of ground effect on takeoff, it experienced an aerodynamic stall as a result of wing contamination,
- The pilot’s decision making was affected by continuation bias, which resulted in the pilot attempting a takeoff with an aircraft contaminated with ice and snow adhering to its critical surfaces,
- The pilot and the passenger seated in the right-hand crew seat were not wearing the available shoulder harnesses. As a result, they sustained serious head injuries during the impact sequence,
- During the impact sequence, the cargo restraint system used to secure the baggage in the rear baggage compartment failed, causing some of the baggage to injure passengers seated in the rear of the aircraft cabin,
- The aircraft was not airworthy at the time of the occurrence as a result of an incomplete airworthiness directive.

Final Report:

Crash of an Antonov AN-148-100B in Stepanovskoye: 71 killed

Date & Time: Feb 11, 2018 at 1427 LT

Type of aircraft:

Antonov AN-148

Operator:

Registration:

RA-61704

Flight Phase:

Cessna 208B Grand Caravan

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Plain, Valley

Schedule:

Moscow – Orsk

MSN:

27015040004

YOM:

2010

Flight number:

6W703

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5039

Captain / Total hours on type:

1323.00

Copilot / Total flying hours:

860

Copilot / Total hours on type:

720

Aircraft flight hours:

16249

Aircraft flight cycles:

8397

Circumstances:

The twin engine aircraft departed runway 14R at Moscow-Domodedovo Airport at 1421LT. Six minutes later, while climbing to an altitude of 6,000 feet in light snow showers, the airplane descended then disintegrated in a snow covered field located in Argunovo, about 37 km southeast of the Airport, one minute later. The aircraft was totally destroyed and debris were scattered on more than one km. All 71 occupants were killed. Both recording systems have been recovered. A day after the crash, Russian Authorities confirmed that the aircraft was intact until the final impact with the ground. Preliminary reports indicates speed variations on all three ASI's three minutes after rotation. 50 seconds after the automatic pilot was disconnected, the airplane experienced vertical loads between 0,5 and 1,5 G. then pitched down to an angle of 35°. Five seconds prior to impact, the airplane banked right to 25°. Preliminary investigations shows that the incorrect data on ASI's was caused by icing of the Pitot tubes as the heating systems was off, apparently because the crew failed to activate it.

Probable cause:

The accident was the consequence of erroneous actions on part of the crew while climbing in instrument meteorological conditions at unreliable readings of instrument speed caused by icing (blockage with ice) of all three Pitot tubes. This caused the aircraft to become uncontrollable, enter a dive and eventually collide with the ground. The accident was then considered as a loss of control in flight (LOC-I). The investigation revealed systemic weaknesses in the identification of hazards and risk control, the inoperability of the airline's flight safety management system and the lack of control over the level of training of crew members by aviation authorities at all levels, which led to the issuance of certificates of aviation personnel and the admission to the flights of the crew, which did not fully meet the qualification requirements. The following contributing factors were reported:
- Hurry of the crew in preparation for the flight due to the late arrival of the aircraft from the previous flight and attempts to "catch up" with the time,
- Skipping by the crew of the operation to switch on the Pitot tube heating before takeoff and failing to comply with the section of the check list "BEFORE TAKE-OFF", which provides for the control of this action,
- Design features of the An-148 aircraft in terms of the restrictions on the duration of Pitot tube heating operation on the ground, which led to the need to carry out operations to control the inclusion of Pitot tube heating and compliance with the principle of "dark cockpit" in a separate section of the "BEFORE THE FLIGHT" check list, which is performed immediately before the start of the takeoff run, which creates additional risks of missing these operations. These actions are provided in the section "ON THE RUNWAY START",
- Systematic failure of the airline's crews to comply with the "dark cockpit" principle and the requirements of the radar, which contributed to "getting used" to the takeoff with the presence of emergency and warning messages on the Integrated system and alarm indicator (KISS) and did not allow to identify the fact that the Pitot tube heating was not included. In the accident flight before takeoff, six warning messages were displayed on the KISS, including three messages about the absence of Pitot tube heating,
- Design features of the An-148 aircraft, connected with the impossibility to disable the display of a number of warning messages on the KISS even when performing the whole range of works provided for by the MMEL while ensuring the flight with delayed defects,
- Low safety culture in the airline, which was manifested in: systematic failure to record in the flight log the failures detected during the flight, as well as in the performance of flights with the failures not eliminated and/or not included in the list of delayed failures, accompanied by the corresponding messages on the KISS,
- Failure to take necessary measures in case of detection of previous facts of untimely activation of Pitot tube heating by crews based on the results of express analysis of flight information,
- Unreadiness of the crew to take actions in case of triggering the alarm "Speed of Emergency" due to the lack of appropriate theoretical training in the airline and the impossibility to work out this special situation on the flight simulation device and / or during airfield training and, as a consequence, failure to comply with the procedures provided for after triggering of this alarm,
- Absence of federal aviation regulations for certification of flight simulators, the development of which is provided for by the Air Code of the Russian Federation,
- Approval for the existing AN-148 flight simulators of the IFC Training LLC and the CTC of the Saint-Petersburg State University of Civil Aviation without taking into account their actual capabilities to reproduce special flight cases, as well as the provisions of FAR-128,
- Absence of specific values of flight parameters (engine operation mode, pitch and roll angles, etc.) in the aircraft's flight manual, which must be maintained by the crew of the airspeed alarm system, as well as absence of the situation with unreliable instrument speed readings (Unreliable Airspeed Procedure) in the list of special flight cases,
- Increased psycho-emotional tension of crew members at the final stage of the flight due to inability to understand the causes of speed fluctuations and, as a consequence, the captain falling under the influence of the "tunnel effect" with the formation of the dominating factor of speed control according to the "own" (left) airspeed indicator without a comprehensive assessment of flight parameters,
- Insufficient training of pilots in the field of human factor, methods of threat and error control and management of crew resources,
- Individual psychological peculiarities of pilots (for the captain - reduction of intellectual and behavioral flexibility, fixation on their own position with the inability (impossibility) to "hear" prompts from the second pilot; for the second pilot - violation of the organization and sequence of actions), which in a stressful situation in the absence of proper level of management of the crew resources came to the fore; loss of the captain's psychological performance (psychological stupor, psychological incapacitation), which resulted in complete loss of spatial orientation and did not allow reacting to correct prompts and actions of the co-pilot, including when triggering the PULL UP warning of the EGPWS system,
- Absence of psychological incapacitation criteria in the airline's AFM, which prevented the second pilot from taking more drastic measures,
- High annual leave arrears for special conditions, which could lead to fatigue and negatively affect the performance of the captain,
- Operation of the aircraft control system in the longitudinal channel in the reconfiguration mode with unreliable signals of instrument speed, not described in the operational documentation, related to a double increase in the transfer coefficient from the hand wheel to the steering wheel in the flight configuration and constant deviation of the steering wheel for diving (without deviation of the steering wheel) for about 60 seconds, which reduced the time required for the crew to recognize the situation.

Final Report:

Crash of a Cessna 208B Grand Caravan in Akobo: 1 killed

Date & Time: Jan 7, 2018 at 1645 LT

Type of aircraft:

Operator:

Registration:

5Y-FDC

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site: