Crash of a Beechcraft C90GTx King Air in Lanseria: 3 killed

Date & Time: Feb 3, 2014 at 0654 LT
Type of aircraft:
Operator:
Registration:
ZS-CLT
Survivors:
No
Schedule:
Johannesburg – Lanseria
MSN:
LJ-2011
YOM:
2011
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1936
Captain / Total hours on type:
101.00
Aircraft flight hours:
500
Circumstances:
The pilot and two passengers were planning to fly from Rand Airport to Lanseria International Airport (FALA) in the early hours of the morning with the intention to clear customs. It was still dark and the weather forecast thunderstorms with rain for most areas of Gauteng. Rand Tower requested clearance from FAOR approach before departure. The aircraft took off from Runway 29 following the clearance given and proceeded in a westerly direction. At 6500 feet above mean sea level (AMSL), Rand handed the aircraft over to Approach for further clearances. Reported visibility at FALA was 600m and the cloud base was 600 feet AGL. The pilot then requested a VHF Omnidirectional range (VOR) Z approach for Runway 07. He started the approach at 8000 feet and approximately 14nm from LIV. At 12nm and established on Radial 245 Approach handed him over to FALA. Once in contact with FALA the pilot was advised of the heading to turn to at missed approach point (MAP). At MAP the pilot did not have the runway in sight and advised tower that they were going around. They turned left 360° and climbed to 8000 feet as instructed by FALA. FALA handed them back to Approach for repositioning for Radial 245. Approach advised the aircraft that visibility at Wonderboom was better but the pilot said if not successful they would route to Polokwane. At 12nm the aircraft was handed over to FALA. During the descent, the pilot started repeating messages more than twice. Close to MAP the pilot indicated that he had the field in sight. FALA gave them landing clearance. Soon after, the pilot said he did not have it in sight. When FALA instructed him to go around and route Polokwane, the pilot came back on frequency indicating that the aircraft was in distress. After that, the tower heard a loud bang accompanied by black smoke from behind a hangar.
Probable cause:
The accident was the consequence of a stall in adverse weather conditions after the pilot suffered a spatial disorientation during a missed approach procedure.
Final Report:

Crash of a PZL-Mielec AN-28 near Addis Ababa

Date & Time: Jan 20, 2014 at 0935 LT
Type of aircraft:
Operator:
Registration:
UP-A2805
Flight Type:
Survivors:
Yes
Schedule:
Entebbe - Sana'a
MSN:
1AJ008-22
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
When flying in the Ethiopian Airspace, the crew informed ATC about engine problems and was cleared to divert to Addis Ababa-Bole Airport for an emergency landing. On approach, the twin engine aircraft crashed in an open field located in Legedadi, about 20 km northeast of the airport. Both pilots were seriously injured and the aircraft was destroyed.

Ground accident of a Boeing 747-436 in Johannesburg

Date & Time: Dec 22, 2013 at 2243 LT
Type of aircraft:
Operator:
Registration:
G-BNLL
Flight Phase:
Survivors:
Yes
Schedule:
Johannesburg – London
MSN:
24054/794
YOM:
1990
Flight number:
BA034
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
185
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20050
Captain / Total hours on type:
12500.00
Copilot / Total flying hours:
5700
Copilot / Total hours on type:
1400
Aircraft flight hours:
110578
Aircraft flight cycles:
12832
Circumstances:
The British Airways aircraft B747-400, flight number BA034 with registration G-BNLL, was going to embark on a commercial international air transportation long haul flight from FAOR to EGLL. The ATC gave the crew instructions to push back, start and face south, then taxi using taxiway Bravo to the Category 2 holding point for Runway 03L. During the taxi, instead of turning to the left to follow Bravo, the crew continued straight ahead, crossing the intersection of taxiway Bravo and aircraft stand taxilane Mike. After crossing the intersection, still being on Mike, the aircraft collided with a building. An investigation was conducted and several causal factors were determined. Amongst others, it was determined that the crew erred in thinking they were still taxiing on Bravo while in fact they were taxiing on Mike. This mistake, coupled with other contributory factors such as the briefing information, taxi information, ground movement visual aids, confusion and loss of situational awareness led to the collision. All 202 occupants evacuated safely while four people in the building were injured. The aircraft was damaged beyond repair.
Probable cause:
The loss of situational awareness caused the crew to taxi straight ahead on the wrong path, crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point. Following aircraft stand taxilane Mike; they collided with a building on the right-hand side of Mike.
Contributory Factors:
- Failure of the crew to carry out a briefing after they had received instruction from ATC that the taxi route would be taxiway Bravo.
- The lack of appropriate knowledge about the taxiway Bravo layout and relevant information (caution notes) on threats or risks to look out for while taxiing on taxiway Bravo en route to the Cat 2 holding point.
- The aerodrome infrastructure problems (i.e. ground movement navigation aids anomalies), which created a sense of confusion during the taxi.
- Loss of situation awareness inside the cockpit causing the crew not to detect critical cues of events as they were gradually unfolding in front of them.
- Failure of the other crew members to respond adequately when the Co-pilot was commenting on the cues (i.e. narrowness and proximity to the building).
- The intersection/junction of Bravo and Mike not being identified as a hotspot area on the charts.
Final Report:

Crash of a Boeing 747-281BSF in Abuja

Date & Time: Dec 4, 2013 at 2119 LT
Type of aircraft:
Operator:
Registration:
EK-74798
Flight Type:
Survivors:
Yes
Schedule:
Jeddah - Abuja
MSN:
23698/667
YOM:
1986
Flight number:
SV6814
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23000
Captain / Total hours on type:
13000.00
Copilot / Total flying hours:
5731
Copilot / Total hours on type:
1296
Aircraft flight hours:
94330
Aircraft flight cycles:
15255
Circumstances:
Following an uneventful cargo flight from Jeddah, the crew completed the approach and landing procedures on runway 04 at Abuja-Nnamdi Azikiwe Airport. During the landing roll, the aircraft overran the displaced threshold then veered to the right and veered off runway. While contacting a grassy area, the aircraft collided with several parked excavator equipment and trucks. The aircraft came to a halt and was severely damaged to both wings and engines. All six occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The accident resulted as the crew was not updated on the information available on the reduced runway length.
The following contributing factors were identified:
1. Lack of briefing by Saudia dispatcher during pre-flight.
2. Runway status was missing from Abuja ATIS information.
3. Ineffective communication between crew and ATC on short finals.
4. The runway markings and lighting not depicting the displaced threshold.
5. The entire runway lighting was ON beyond the displaced threshold.
Final Report:

Crash of an Antonov AN-26B in Omega

Date & Time: Nov 30, 2013
Type of aircraft:
Registration:
NAF-3-642
Flight Type:
Survivors:
Yes
Schedule:
Windhoek - Omega AFB
MSN:
144 01
YOM:
1985
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Windhoek on a special flight to the disused Airfield of Omega (ex airbase), carrying six crew members and various equipment in order to collect the bodies of all 33 people who have been killed in the crash of the LAM Embraer ERJ-190AR C9-EMC that occurred in the Bwabwata National Park the previous day. The aircraft landed too far down the airstrip that was overgrown by grass and bushes. Unable to stop within the remaining distance, the aircraft overran and collided with trees, causing severe damages to the wings (the right wing was partially torn off). All six occupants escaped unhurt while the aircraft was damaged beyond repair. Hulk still in situ in FEB2014 and may be disassembled and trucked back to Windhoek.
Probable cause:
Wrong landing configuration. Disused airport and runway in poor condition.

Crash of an Embraer ERJ-190AR in the Bwabwata National Park: 33 killed

Date & Time: Nov 29, 2013 at 1230 LT
Type of aircraft:
Operator:
Registration:
C9-EMC
Flight Phase:
Survivors:
No
Schedule:
Maputo - Luanda
MSN:
190-00581
YOM:
2012
Flight number:
LAM470
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
33
Captain / Total flying hours:
9052
Captain / Total hours on type:
2519.00
Copilot / Total flying hours:
1183
Copilot / Total hours on type:
101
Aircraft flight hours:
2905
Aircraft flight cycles:
1877
Circumstances:
Aircraft left Maputo Airport at 1126LT on flight LAM470 to Luanda, Angola. En route, while overflying Botswana and Namibia, aircraft encountered bad weather conditions with CB's at high altitude and turbulence. In unknown circumstances, aircraft went out of control and disappeared from radar screens at 1230LT, most probably after diving into the ground. As the aircraft did not arrive at Luanda, SAR commenced but were suspended by night due to low visibility and bad weather conditions (heavy rain falls). The day after, on 30NOV, Namibia Police forces announced they located the wreckage in the Bwabwata National Park, near Divundu. Aircraft was completely destroyed by impact forces and post impact fire. All 33 occupants were killed, among them 16 Mozambicans, 9 Angolans, 5 Portuguese, one French, one Brazilian and one Chinese. The aircraft crashed in a dense wooded and isolated area, sot SAR are difficult. No distress call was sent by the crew.
Probable cause:
A press conference provided by the Mozambican authorities on 21DEC2013 reported that CVR analysis revealed that the captain was alone in the cockpit which was locked. The copilot tried to enter without success and was knocking on the door several times, without answer or any reaction on part of the captain who engaged the aircraft in a descent rate of 6,000 feet per minute until impact with the ground. Several warning sounds and alarms were not responded to. On April 15, 2016, the Directorate of Aircraft Accident Investigations (DAAI) of Namibia confirmed in its final report that the accident was caused by the inputs to the auto flight systems by the person believed to be the Captain, who remained alone on the flight deck when the person believed to be the co-pilot requested to go to the lavatory, caused the aircraft to departure from cruise flight to a sustained controlled descent and subsequent collision with the terrain. Investigations revealed that the captain suffered personal events during the past year, such as a divorce, the death of his son in a car crash and one of his daughter that underwent heart surgery.
Final Report:

Crash of a Cessna 208B Grand Caravan in Likawage

Date & Time: Oct 11, 2013
Type of aircraft:
Operator:
Registration:
5H-KEN
Flight Phase:
Survivors:
Yes
Schedule:
Likawage – Dar es Salaam
MSN:
208B-0384
YOM:
1994
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft was engaged in a charter flight from Likawage to Dar es Salaam, carrying one passenger and two pilots. Ready for takeoff at threshold, the crew applied full power and maintained brakes. Despite the engine did not reach the takeoff power, the captain released brakes and initiated the takeoff roll. The aircraft rolled for about three-quarters of the runway when the engine reached the takeoff power. But the aircraft failed to rotate, continued, overran and eventually collided with trees, bursting into flames. All three occupants were slightly injured and the aircraft was partially destroyed by fire.

Crash of an Embraer EMB-120ER Brasília in Lagos: 16 killed

Date & Time: Oct 3, 2013 at 0932 LT
Type of aircraft:
Operator:
Registration:
5N-BJY
Flight Phase:
Survivors:
Yes
Schedule:
Lagos - Akure
MSN:
120-174
YOM:
1990
Flight number:
SCD361
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
20068
Captain / Total hours on type:
1309.00
Copilot / Total flying hours:
4660
Copilot / Total hours on type:
3207
Aircraft flight hours:
27362
Aircraft flight cycles:
34609
Circumstances:
The crew discussed some concerns about the aircraft prior to departure but at this time we are not prepared to elaborate on those concerns as there remains a lot of work to complete on the CVR analysis in order to determine the specific nature of the crew’s concerns. Associated 361 was cleared for take-off on runway one eight left at Lagos international airport. The wind was calm and weather is not considered a factor in this accident. Approximately 4 seconds after engine power was advanced to commence the take-off roll, the crew received an automated warning from the onboard computer voice which consisted of three chimes followed by “Take-off Flaps…Take-off Flaps”. This is a configuration warning that suggests that the flaps were not in the correct position for take-off and there is some evidence that the crew may have chosen not to use flaps for the take-off. The warning did not appear to come as any surprise to the crew and they continued normally with the take-off. This warning continues throughout the take-off roll. As we are in the process of verifying the accuracy of the flight data, we have not yet been able to confirm the actual flap setting however we expect to determine this in the fullness of time. It was determined from the CVR that the pilot flying was the Captain and the pilot monitoring and assisting was the First Officer. The ‘set power‘ call was made by the Captain and the ‘power is set’ call was confirmed by the First Officer as expected in normal operations. Approximately 3 seconds after the ‘power is set’ call, the First Officer noted that the aircraft was moving slowly. Approximately 7 seconds after the ‘power is set’ call, the internal Aircraft Voice warning system could be heard stating ‘Take off Flaps, Auto Feather’. Auto feather refers to the pitch of the propeller blades. In the feather position, the propeller does not produce any thrust. The FDR contains several engine related parameters which the AIB is studying. At this time, we can state that the Right engine appears to be producing considerably less thrust than the Left engine. The left engine appeared to be working normally. The aircraft automated voice continued to repeat ‘Take-off Flaps, Auto Feather’. The physical examination of the wreckage revealed that the right engine propeller was in the feather position and the engine fire handle was pulled/activated. The standard ‘eighty knots’ call was made by the First Officer. The first evidence that the crew indicated that there was a problem with the take-off roll was immediately following the ‘eighty knots’ call. The First Officer asked if the take- off should be aborted approximately 12 seconds after the ‘eighty knots’ callout. Our investigation team estimates the airspeed to be approximately 95 knots. Airspeed was one of the parameters that, while working in the cockpit, appeared not to be working on the Flight Data Recorder. We were able to estimate the speed based on the radar data that we synchronized to the FDR and CVR but it is very approximate because of this. In response to the First Officer’s question to abort, the Captain indicated that they should continue and they continued the take-off roll. The crew did not make a ‘V1’ call or a Vr’ call. V1 is the speed at which a decision to abort or continue a take-off is made. Vr is the speed at which it is planned to rotate the aircraft. Normally the non-flying pilot calls both the V1 and the Vr speeds. When Vr is called the flying pilot pulls back on the control column and the aircraft is rotated (pitched up) to climb away from the runway. During the rotation, the First Officer stated ‘gently’, which we believe reflects concern that the aircraft is not performing normally and therefore needs to be rotated very gently so as not to aerodynamically stall the aircraft. The First Officer indicated that the aircraft was not climbing and advised the Captain who was flying not to stall the aircraft. Higher climb angles can cause an aerodynamic stall. If the aircraft is not producing enough overall thrust, it is difficult or impossible to climb without the risk of an aerodynamic stall. Immediately after lift-off, the aircraft slowly veered off the runway heading to the right and was not climbing properly. This aircraft behavior appears to have resulted in the Air Traffic Controller asking Flight 361 if operation was normal. Flight 361 never responded. Less than 10 seconds after rotation of the aircraft to climb away from the runway, the stall warning sounded in the cockpit and continued to the end of the recording. The flight data shows characteristics consistent with an aerodynamic stall. 31 seconds after the stall warning was heard, the aircraft impacted the ground in a nose down near 90° right bank.
Probable cause:
The accident was the consequence of the decision of the crew to continue the take-off despite the abnormal No. 2 Propeller rpm indication and a low altitude stall as a result of low thrust at start of roll for take-off from No. 2 Engine caused by an undetermined malfunction of the propeller control unit.
The following contributing factors were identified:
- The aircraft was rotated before attaining V1.
- The decision to continue the take-off with flap configuration warning and auto- feather warning at low speed.
- Poor professional conduct of the flight crew.
- Inadequate application of Crew Resource Management (CRM) principles.
- Poor company culture.
- Inadequate regulatory oversight.
Final Report:

Crash of a PZL-Mielec AN-2R in Kamako

Date & Time: Sep 13, 2013 at 1150 LT
Type of aircraft:
Operator:
Registration:
9Q-CFT
Survivors:
Yes
Schedule:
Tshikapa - Kamako
MSN:
1G223-14
YOM:
1987
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16798
Captain / Total hours on type:
16000.00
Aircraft flight hours:
6981
Circumstances:
Following an uneventful flight from Tshikapa, the pilot initiated the approach to Kamako Airfield in relative good conditions. On final, the wind component suddenly changed. The aircraft lost height and impacted ground 16 metres short of runway 12. Upon impact, the undercarriage were partially torn off and the aircraft slid before coming to rest 37 metres past the runway threshold. All six occupants, one pilot and five passengers, escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the loss of control that occurred on short final was the result of the combination of a human error and weather component. The pilot was surprised by the abrupt change in weather conditions on short final to Kamako runway 12. He elected to initiate a go-around procedure and increased engine power but unfortunately, low level windshear caused the aircraft to lose height and to struck the ground as its speed was insufficient. In consequence, the increase power was too low to allow the pilot to maintain the approach profile. The torsion of the blades confirmed that the engine was at full power for a go-around procedure at impact. The absence of a windsock at Kamako Airfield was considered as a contributing factor as this would help the pilot to recognize the wind component and to decide to land or to go-around in due time.
Final Report:

Crash of an Antonov AN-26B-100 in Guriceel

Date & Time: Aug 25, 2013 at 1604 LT
Type of aircraft:
Operator:
Registration:
EK-26818
Survivors:
Yes
Schedule:
Mogadishu – Guriceel
MSN:
141 01
YOM:
1990
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
45
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a special flight from Mogadishu to Guriceel, carrying 5 crew members and 45 passengers, among them Hussein Ali Wehliye, the new governor of the Galguduud Province. Following an uneventful flight, the aircraft landed too far down the runway and was unable to stop within the remaining distance. It overran and hit a rock which caused the nose gear to collapse and to penetrated the cockpit floor, injuring a crew member. All 49 other occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
It is believed that, following a wrong approach configuration, the aircraft landed too far down the runway, reducing the landing distance available. In such situation, the aircraft could not be brought to a safe halt. As the landing maneuver was obviously missed, the crew should initiate a go-around procedure. It was also reported that the aircraft CofA expired 31 May 2012 and that the aircraft was removed from the Armenian registered on 26 Oct 2012.