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.

Crash of a Beechcraft 200C Super King Air in Lake Manyara

Date & Time: Aug 22, 2013
Operator:
Registration:
5H-TZW
Flight Phase:
Survivors:
Yes
Schedule:
Bukoba - Zanzibar - Dar es-Salaam
MSN:
BL-17
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route to Zanzibar, while cruising at an altitude of 21,000 feet, the right engine failed. The pilot decided to divert to Arusha Airport when few minutes later, while passing 16,000 feet on descent, the left engine failed as well. The pilot attempted to ditch the aircraft into Lake Manyara. The aircraft belly landed and came to rest in shallow water, bent in two. All seven occupants were rescued by fishermen and the aircraft was damaged beyond repair.

Crash of an Antonov AN-12BP in Mogadishu: 4 killed

Date & Time: Aug 9, 2013 at 0800 LT
Type of aircraft:
Operator:
Registration:
1513
Flight Type:
Survivors:
Yes
Schedule:
Dire Dawa - Mogadishu
MSN:
4 3 420 09
YOM:
1964
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The four engine aircraft departed Dire Dawa on a special flight to Mogadishu, carrying 6 crew members and a load consisting of weapons and ammunition intended for the AMISOM, the African Union Mission in Somalia. After landing, the aircraft skidded on runway, overran and crashed against a perimeter wall, bursting into flames. The aircraft was destroyed by impact forces and a post impact fire fed by ammunition which caused multiple explosions. Four crew were killed while two others were seriously injured.
Probable cause:
It is believed that the control was lost after landing following a possible multiple tyre burst.

Crash of a Cessna 404 Titan II near Merugwayi

Date & Time: Jul 30, 2013
Type of aircraft:
Operator:
Registration:
5Y-DOC
Flight Phase:
Survivors:
Yes
Schedule:
Merugwayi - Arusha
MSN:
404-0433
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from a remote airstrip in Merugwayi, while flying in bad weather conditions, the twin engine aircraft crashed in a wilderness located in Kapingiro, near Merugwayi. All seven occupants were injured, the copilot aged 23 seriously. The aircraft was damaged beyond repair. Among passengers were several doctors who provided medical services to locals leaving in the remote district.

Crash of a Partenavia P.68 Observer in the Dzalanyama Forest Reserve

Date & Time: Jul 16, 2013 at 0900 LT
Type of aircraft:
Operator:
Registration:
ZS-LSX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tete – Lilongwe – Dar es-Salaam
MSN:
323-16-OB
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed South Africa on a flight to Tanzania with intermediate stops in Tete and Lilongwe, carrying one passenger and one pilot. The aircraft was en route to Dar es-Salaam to perform a Lidar (Laser Imaging Detection And Ranging) mission. En route, the pilot encountered engine problems and elected to make an emergency landing. Upon landing in an open field, the aircraft lost its tail and crashed landed about 45 km southwest of Lilongwe. Both occupants were rescued and the aircraft was destroyed.

Crash of an Embraer EMB-110P1 Bandeirante in Francistown: 2 killed

Date & Time: Jun 29, 2013 at 0700 LT
Operator:
Registration:
ZS-NVB
Flight Type:
Survivors:
No
Schedule:
Lanseria - Francistown - Lubumbashi
MSN:
110-479
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was performing a cargo flight from Lanseria to Lubumbashi with an intermediate stop at Francistown Airport to refuel, and the aircraft was carrying a load of ion exchange resins for water purification. During an early morning approach, the crew encountered poor visibility due to foggy conditions, abandoned the approach and initiated a go-around procedure. During a second approach from the opposite direction, the crew informed ATC he established a visual contact with the runway when the aircraft crashed in a bushy area located some 4,6 km short of runway.

Crash of a Cessna 208 Caravan I in N'Gaoundéré: 1 killed

Date & Time: Jun 10, 2013 at 1000 LT
Type of aircraft:
Operator:
Registration:
TT-BAU
Survivors:
Yes
Schedule:
Moundou - Douala
MSN:
208-0045
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft departed Moundou (Chad) on a flight to Douala, Cameroon, carrying three passengers and two pilots on behalf of CotonTchad, the Chadian National Coton Company (Société Cotonnière du Tchad). En route, the crew informed ATC about engine problems and elected to divert to N'Gaoundéré Airport. On final approach, the aircraft stalled and crashed in a marshy field located near the airport. All five occupants were injured, both crew seriously. Few hours later, the captain died from his injuries. The aircraft was destroyed.
Probable cause:
Engine trouble for unknown reasons.