Ground accident of an Embraer EMB-120RT Brasília in Manaus

Date & Time: Aug 13, 2002 at 1225 LT
Type of aircraft:
Operator:
Registration:
PT-WGE
Flight Phase:
Survivors:
Yes
Schedule:
Humaitá – Manaus
MSN:
120-004
YOM:
1986
Flight number:
RLE4847
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13474
Captain / Total hours on type:
518.00
Copilot / Total flying hours:
4110
Copilot / Total hours on type:
3660
Aircraft flight hours:
26756
Circumstances:
Following an uneventful flight from Humaitá, the crew completed the landing at Manaus-Eduardo Gomes Airport. After taxi, the crew was approaching the apron when he feathered the propellers and applied the brakes as they wanted to stop the aircraft. There was no deceleration despite both crew applied brakes. The copilot suggested to use reverse thrust but this was not possible as the propellers were already feathered. Out of control, the aircraft struck a brick building, damaging the left engine, and the right landing gear fell into a drainage ditch, approximately one meter deep. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following factors were identified:
- The crew did not have sufficient training to enable the desired assertiveness for the correct use of aircraft resources, which would probably have prevented the accident, since, instead of applying the emergency brake, they applied reverse with the feathered props, contrary to the procedure provided for in the Aircraft Manual.
- The maintenance services were not efficient, as they did not comply with the Aircraft Maintenance Manual in relation to the dimensional adjustment of the Hub Cap Drive Clips' drive clips, and the Service Bulletin incorporated stickers to the outer doors of the main landing gear, as a reminder to the mechanic to check the clearances.
- The copilot failed to apply the reverse pitch on the propellers as they were feathered, and at that moment the emergency brake should be commanded to brake the aircraft.
- The company failed to adequately check the execution of the actions provided for in the Aircraft Maintenance Manual regarding the 'Antiskid' system and to verify the application of all service bulletins issued by the manufacturer.
Final Report:

Ground accident of an Airbus A300B2-101 in New Delhi

Date & Time: Mar 8, 2002 at 0315 LT
Type of aircraft:
Operator:
Registration:
VT-EFW
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
111
YOM:
1980
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A group of five technicians/engineers of the company was preparing the aircraft to be transferred to a hangar for maintenance. After engine startup, the power was reduced to idle after someone inadvertently pulled out the circuit breaker. The aircraft jumped the chocks and started to roll. Since the engine's power was in idle, the brakes and the nosewheel steering system were inoperative. The crew elected to reduce power on the left engine but mistakenly increased the power on the right engine by 90%. This caused the aircraft to rotate 80° when control was lost. The airplane rolled through a perimeter wall, causing the nose gear to collapse. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Ground accident of a Douglas DC-8-62F in Singapore

Date & Time: Feb 28, 2002 at 0044 LT
Type of aircraft:
Operator:
Registration:
N1808E
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
46105/494
YOM:
1969
Flight number:
APWP6L
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5000
Copilot / Total flying hours:
4300
Circumstances:
On 28 February 2002, Arrow Air flight APWP6L touched down on Runway 02L at Singapore Changi Airport at 0029 hours. The weather and visibility conditions were good (visibility in excess of 10 km). Arrow Air flight APWP6L was assigned to park at Bay 117, a remote aircraft parking bay. After APWP6L had landed, the runway controller at Changi Tower instructed the aircraft to taxi towards Bay 117. The aircraft exited the runway via rapid exit Taxiway W4. The ground movement planner at Changi Tower selected the taxiway centre line lights to guide the aircraft from Taxiway W4 onto Taxiway NC1, Taxiway WA and to Bay C7 (Bay 117 is the second parking bay after Bay C7). Due to airside construction works, there was no taxiway centre line lighting guidance on the short segment of taxi route from Taxiway WA from abeam Bay C7 to the adjacent parking Bays 117 and 118. There was a NOTAM in force that stipulated that during hours of darkness, aircraft could only be towed in to Bays 117 and 118. On reaching Bay C7, the flight crew of APWP6L did not stop but continued taxiing past Bay C7 onto a diverted portion of Taxiway WA. The taxiway centre line lights for this diverted portion of Taxiway WA were not switched on by ATC as it was not the intended route for the aircraft. At about 0037 hours, flight APWP6L called Changi Tower to indicate its position near Bay 106. Realising that flight APWP6L had missed its allocated parking position, the ground movement planner at Changi Tower routed the aircraft back to Bay 117 via Taxiways WA, SC, WP, V8 and Taxiway WA. Flight APWP6L followed the return route until it was abeam Bay 117 on the straight section of the diverted portion of Taxiway WA, just before Taxiway VY. At that location, the pilot saw the ground marshaller at Bay 117 on the aircraft’s right side. Instead of continuing to follow the assigned taxi route, the aircraft turned right. In doing so, it left the WA taxiway centre line and went onto a grass area between Taxiway WA and the parking apron. The nose gear of the aircraft went across an open drain of about 1.4 m wide and 0.8 m deep within the grass area. The aircraft came to a halt when its main landing gears went into the drain at about 0044 hours. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- The accident took place at night in clear weather.
- The flight crew members were properly licensed, qualified, medically fit, and in compliance with flight and duty time regulations.
- The flight crew had the latest revision of the Jeppesen charts showing the layout of Singapore Changi Airport, including the yellow supplementary chart showing the area near Bay 117 in greater detail.
- The flight crew was not familiar with the Terminal 1 West Apron area where Bay 117 was located.
- The flight crew was aware of the NOTAM tow-in requirement at Bay 117 during hours of darkness.
- The Apron Control duty supervisor was aware of the requirement for aircraft to be towed into Bay 117. He did not coordinate with ATC and the ground handler on towing arrangements as there was no towing procedure established for aircraft assigned to Bay 117 or 118.
- The runway controller was not aware of the requirement for aircraft to be towed into Bay 117. He instructed flight APWP6L to follow the green lights to Bay 117 in accordance with standard ATC procedures.
- The flight crew did not stop at Bay C7 to ask for instructions or guidance to get to Bay 117.
- After missing Bay 117 initially, the flight crew continued taxiing in search of the bay on their own.
- On the subsequent return towards Terminal 1 West Apron, after sighting Bay 117 and the marshaller on the right of the aircraft, the flight crew deviated from the Taxiway WA centre line marking and green centre line lights and turned the aircraft to the right directly towards Bay 117.
- The flight crew did not see a turn signal from the marshaller but believed they saw the marshaller waving a “move ahead” signal.
- The flight crew did not notice on the Jeppesen charts that there was a turf island separating Taxiway WA from the parking apron where Bay 117 was located.
- The flight crew turned right from the straight section of the diverted portion of Taxiway WA to head directly towards Bay 117 even though there was no turn signal from the marshaller, no instruction to turn from ATC and no aircraft parking bay guidance marking on the ground to indicate to the flight crew to turn right.
- The landing lights of the aircraft were turned on.
- As taxiway centre line lights were provided along Taxiway WA, according to ICAO Annex 14, there was no requirement for taxiway edge lights to be provided. However, where there is a large unmarked paved area adjacent to a taxiway, the provision of taxiway edge lights or reflective markers (in addition to taxiway centre line lights) would provide an additional cue to pilots to stay within the taxiway. This may help to prevent pilots inadvertently straying off the taxiway.
- There were no edge lights or markers to show the grass area between Taxiway WA and the parking apron where Bay 117 was located. There is no requirement in ICAO Annex 14 for edge lights or markers to show the presence of grass areas adjacent to taxiways.
- The drain located within the grass area between the diverted portion of Taxiway WA and the parking apron was outside the taxiway strip. According to ICAO Annex 14, drains located outside a taxiway strip are not required to be covered.
- The airworthiness of the aircraft was not a factor in this accident.
Final Report:

Crash of a Cessna 525A CitationJet Cj2 in Milan: 4 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
D-IEVX
Flight Phase:
Survivors:
No
Schedule:
Cologne - Milan - Paris
MSN:
525A-0036
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5000
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
12000
Copilot / Total hours on type:
2000
Aircraft flight hours:
28
Aircraft flight cycles:
20
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end. Both pilots were German citizens while both passengers were respectively Mr. Stefano Romanello, representative for Cessna Aircraft in Europe and Mr. Luca Fossati, President of the Star food group.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Ground accident of a Boeing 747-368 in Kuala Lumpur

Date & Time: Aug 23, 2001 at 2208 LT
Type of aircraft:
Operator:
Registration:
HZ-AIO
Flight Phase:
Survivors:
Yes
Schedule:
Kuala Lumpur - Jeddah
MSN:
23266
YOM:
1985
Flight number:
SV3830
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following technical problems with the engines, the aircraft was transferred to a hangar at Kuala Lumpur for maintenance. In the evening, a team of six technicians was dispatched to convoy the aircraft to the main terminal where 319 passengers should embark on a flight to Jeddah. While on a taxiway, the engineers attempted to turn to another taxiway when control was lost. The aircraft veered off taxiway and came to rest, nose first, in a drainage ditch. All six occupants were injured and the aircraft was damaged beyond repair. At the time of the accident, only the engine n°2 and 3 only were running and it is believed that the auxiliary hydraulic pump switches were in the OFF position. Thus, the nosewheel steering system was inoperative as well as the brakes.

Ground accident of a Boeing 727-287 in Buenos Aires

Date & Time: Jan 9, 2001 at 1720 LT
Type of aircraft:
Operator:
Registration:
CP-2323
Flight Phase:
Survivors:
Yes
Schedule:
Buenos Aires - Santa Cruz
MSN:
22605/1787
YOM:
1981
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was taxiing at Buenos Aires-Ezeiza-Ministro Pistarini Airport for a departure from runway 11 when the left main gear collapsed. All 146 occupants evacuated safely but the aircraft was considered as damaged beyond repair.
Probable cause:
It was determined that the left main landing gear collapsed because the forward trunnion bearing support fitting broke due to intergranular corrosion.

Crash of a Short 330-200 in Paris: 1 killed

Date & Time: May 25, 2000 at 0252 LT
Type of aircraft:
Operator:
Registration:
G-SSWN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Luton
MSN:
3064
YOM:
1981
Flight number:
SSW200
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2240
Captain / Total hours on type:
1005.00
Copilot / Total flying hours:
4370
Copilot / Total hours on type:
14
Aircraft flight hours:
15215
Aircraft flight cycles:
19504
Circumstances:
The Short was departing Paris-Roissy-CDG Airport on a cargo service to Luton with two pilots on board. The crew were cleared to depart cargo stand N51 and proceed to runway 27 at 02:38. Around the same time Air Liberté Flight 8807 (an MD-83, F-GHED) also taxied to runway 27 for a flight to Madrid. At 02:44 the Charles de Gaulle ground controller asked Streamline 200 if they wished to enter runway 27 at an intermediate taxiway; the crew asked for and were granted to enter Taxiway 16. At 02:50:49 the tower controller cleared the MD-83 for takeoff: "Liberté 8807, autorisé au décollage 27, 230°, 10 à 15 kts.". The controller then immediately told the Shorts to line up and wait: "Stream Line two hundred line up runway 27 and wait, number two". As the MD-83 was travelling down the runway, the Shorts started to taxi onto the runway. At a speed of about 155 knots the left wing of MD-83 slashed through the cockpit of the Shorts plane; the MD-83 abandoned takeoff.
Probable cause:
The following findings were identified:
- Firstly, by the LOC controller’s erroneous perception of the position of the aircraft, this being reinforced by the context and the working methods, which led him to clear the Shorts to line up,
- Secondly, by the inadequacy of systematic verification procedures in ATC which made it impossible for the error to be corrected,
- Finally, by the Shorts’ crew not dispelling any doubts they had as to the position of the 'number one' aircraft before entering the runway.
Contributory factors include:
- Light pollution in the area of runway 27, which made a direct view difficult for the LOC controller,
- Difficulty for the LOC controller in accessing radar information: the ASTRE image was difficult to read and the AVISO image not displayed at his control position,
- The use of two languages for radio communications, which meant that the Shorts crew were not conscious that the MD 83 was going to take off,
- The angle between access taxiway 16 and the runway which made it impossible for the Shorts crew to perform a visual check before entering the runway,
- The lack of coordination between the SOL and LOC controllers when managing the Shorts, exacerbated by the presence of a third party whose role was not defined,
- A feedback system which was recent and still underdeveloped.
Final Report:

Ground accident of an Airbus A300B4-203 in Dakar

Date & Time: Feb 12, 2000 at 0056 LT
Type of aircraft:
Operator:
Registration:
TU-TAT
Flight Phase:
Survivors:
Yes
Schedule:
Dakar - Paris
MSN:
282
YOM:
1983
Flight number:
RK304
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
171
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
38400
Aircraft flight cycles:
19600
Circumstances:
While taxiing for departure at Dakar-Yoff Airport, the left main gear unsafe alarm came on in the cockpit panel. The captain decided to return to the apron to proceed to an inspection when the left main gear collapsed. The engine n°1 struck the ground and partially torn off. A fire erupted and quickly spread to the left wing. All 182 occupants evacuated safely but the aircraft was considered as damaged beyond repair. It just came out from a C Check maintenance program.
Probable cause:
A crossing of the flexible tubing of the hydraulic connection controlling the locking of the left gear failed, causing the left main gear to retract.

Ground fire of an Airbus A300B2-203 in Tehran

Date & Time: Feb 1, 2000 at 1030 LT
Type of aircraft:
Operator:
Registration:
EP-IBR
Flight Phase:
Survivors:
Yes
MSN:
61
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Aircraft flight hours:
33700
Aircraft flight cycles:
28100
Circumstances:
The aircraft was towed at Tehran-Mehrabad Airport when it was struck by a IRIAF Lockheed C-130 Hercules that crashed on takeoff. At impact, both aircraft exploded and were totally destroyed by a post crash fire. All six crew members on board the Hercules were killed as well as three people who were on board the Airbus.
Probable cause:
It is believed that the Hercules went out of control upon takeoff following an engine failure.

Ground fire of an IAI-1124A Westwind II in Milwaukee

Date & Time: Dec 26, 1999 at 0715 LT
Type of aircraft:
Registration:
N422BC
Flight Phase:
Survivors:
Yes
Schedule:
Milwaukee - Waukesha
MSN:
302
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14363
Captain / Total hours on type:
2024.00
Aircraft flight hours:
7975
Circumstances:
During the activation of the crew oxygen system a fire erupted which consumed the entire pressure vessel. Representatives from the National Aeronautics and Space Administration's (NASA) Johnson Space Center (JSC), White Sands Testing Facility (WSTF), Las Cruces, New Mexico, examined the retained oxygen system components. Examination of these components revealed that the fire's initiation location was the first stage pressure reducer located in the oxygen regulator assembly.
Probable cause:
The failure of the first stage pressure reducer in the oxygen regulator assembly.
Final Report: