Crash of an Antonov AN-12BP near Tatal: 7 killed

Date & Time: May 11, 2004 at 1018 LT
Type of aircraft:
Operator:
Registration:
ST-SIG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Juba - El Obeid
MSN:
14 001 01
YOM:
1961
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Aircraft flight hours:
16609
Aircraft flight cycles:
7753
Circumstances:
En route from Juba to El Obeid, while cruising at an altitude of 24,000 feet, all four engines flamed out. The crew feathered the propeller, reduced his altitude and attempted an emergency landing when the aircraft struck the ground and crashed against trees. One occupant was seriously injured while six others were killed. Few hours later, the only survivor died from his injuries. It was reported that the aircraft was performing several round trips between Juba and El Obeid since May 9, each time with 9018 kgs of fuel uplifted in El Obeid while the average fuel consumption for a round trip was 10000 kgs. The crew was composed of an Armenian captain and ground engineer, a Sudanese first officer, a Sudanese navigator, a Sudanese radio operator, an Iraqi navigator and an Iraqi flight engineer.
Probable cause:
The following findings were identified:
- Fuel starvation due to Company fuel planning policy,
- The exhaustion of the Captain as he was handling all flights during the three days preceding the accident flight in addition to the weather on day of accident,
- Some of the crew members had limited experience on the type and three of them even did not fly on AN-12 for a long time which might aggravate the situation before the crash,
- The Sudanese navigator license was expired since July 2001,
- The Iraqi crew members did not have any valid licenses and their experience on the An-12 dated back from 1994,
- The aircraft's Certificate of Release to Service and Certificate of Maintenance Review both expired on April 30, 2004.

Crash of a Let L-410UVP in Jiech: 6 killed

Date & Time: May 7, 2004 at 1500 LT
Type of aircraft:
Operator:
Registration:
9XR-EF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jiech – Ayod
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft was chartered by a Sudanese Development Unit to deliver medics and other supplies to a school project in Ayod. Shortly after takeoff from Jiech Airport, while in initial climb, the twin engine aircraft stalled and crashed. One pilot and five passengers were killed while four other occupants were injured. Both pilots were New Zealand's citizens. It seems that the cargo shifted after takeoff, causing the aircraft to stall and crash.

Crash of a Cessna 404 Titan II in Nampula: 2 killed

Date & Time: Apr 20, 2004
Type of aircraft:
Operator:
Registration:
ZS-NVD
Flight Phase:
Survivors:
No
MSN:
404-0667
YOM:
1980
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Nampula Airport, while in initial climb, the aircraft went out of control and crashed, killing both occupants. They were engaged in a geological mission on behalf of the Mozambican government in the north part of the country.

Crash of a Canadair CL-66B Cosmopolitan in Shabunda

Date & Time: Apr 3, 2004
Registration:
3D-ZOE
Flight Type:
Survivors:
Yes
MSN:
CL-66B-6
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the aircraft landed hard at Shabunda Airport. Upon landing, the nose gear collapsed and the airplane came to rest on the runway. Nobody was injured but the airplane was damaged beyond repair.

Crash of a Boeing 707-366C in Cairo

Date & Time: Apr 2, 2004 at 0500 LT
Type of aircraft:
Operator:
Registration:
SU-AVZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cairo - Ostend
MSN:
20762
YOM:
1973
Flight number:
MHS200
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During a night takeoff from Cairo-Intl Airport runway 23L, the right main gear collapsed. The aircraft went out of control, veered off runway to the right and came to rest few hundred metres further with both right engines n°3 & 4 torn off. All seven occupants escaped uninjured.

Crash of a Cessna 208B Grand Caravan in Lake Manyara

Date & Time: Mar 17, 2004 at 0615 LT
Type of aircraft:
Operator:
Registration:
5H-MUA
Flight Phase:
Survivors:
Yes
Schedule:
Arusha – Lake Manyara – Klein’s Camp – Grumet – Seronera – Lake Manyara – Arusha
MSN:
208B-0487
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Circumstances:
The aircraft was operating a scheduled flight starting from its base at Arusha. It was to call at Lake Manyara, Klein’s Camp, Grumet and Seronera before returning to Arusha via Lake Manyara. 5H-MUA took off from Arusha at 0530 hours. It was carrying one pilot and 3 passengers. The VFR flight to Lake Manyara was uneventful and the aircraft landed at Lake Manyara at 0555 hours. Five more passengers joined the flight here and 5H-MUA subsequently took off for Klein’s Camp at 0615 hours. During initial climb, the engine failed. The pilot feathered the propeller and attempted an emergency landing on a road. But he was forced to make an evasive manoeuvre because of a truck. The aircraft lost speed and height, collided with a stone wall beside the road and came tor rest. All nine occupants were rescued, among them five were seriously injured.
Probable cause:
Engine failure for undetermined reasons.
Final Report:

Crash of a Beechcraft 1900D in Ghardaïa: 1 killed

Date & Time: Jan 28, 2004 at 2101 LT
Type of aircraft:
Operator:
Registration:
7T-VIN
Survivors:
Yes
Schedule:
Hassi R’Mel – Ghardaïa
MSN:
UE-365
YOM:
1999
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
1742
Circumstances:
The aircraft departed Hassi R'Mel-Tilrhempt Airport at 2030LT on a 15-minutes charter flight to Ghardaïa, carrying three crew members and two employees of the Sonatrach (Société Nationale pour le Transport et la Commercialisation d’Hydrocarbures). At 2044LT, the crew was cleared for a right hand circuit in preparation for an approach to runway 30. At that moment a Boeing 727 inbound from Djanet was on long finals. The copilot stated that he intended to carry out an NDB/ILS approach to runway 30. The captain however preferred a visual approach. The copilot carried out the captain's course and descent instructions with hesitation. At 2057LT, the EGPWS alarm sounded. Power was added and a climb was initiated from a lowest altitude of 240 feet above ground level. The captain then took over control and assumed the role of Pilot Flying. The airplane manoeuvred south of the airport until 2101LT when the copilot saw the runway. The captain rolled left to -57° and pitched down to -18.9° in order to steer the airplane towards the runway. Again the EGPWS sounded but the descent continued until the airplane impacted the ground and broke up. All five occupants were injured and the aircraft was destroyed. A day later, the copilot died from his injuries.
Probable cause:
The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

Crash of an Ilyushin II-18D in Luena

Date & Time: Jan 27, 2004 at 1440 LT
Type of aircraft:
Operator:
Registration:
ER-ICJ
Flight Phase:
Survivors:
Yes
Schedule:
Luena – Luanda
MSN:
186 0091 02
YOM:
1966
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 29, the aircraft did not accelerate as expected. The captain decided to abort the takeoff procedure but the aircraft could not be stopped within the remaining distance. It overran and collided with trees located 100 meters further. A crew member was injured and the aircraft was damaged beyond repair.

Crash of a Boeing 737-3Q8 off Sharm el-Sheikh: 148 killed

Date & Time: Jan 3, 2004 at 0445 LT
Type of aircraft:
Operator:
Registration:
SU-ZCF
Flight Phase:
Survivors:
No
Schedule:
Sharm el-Sheikh - Cairo - Paris
MSN:
26283
YOM:
1992
Flight number:
FSH604
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
135
Pax fatalities:
Other fatalities:
Total fatalities:
148
Captain / Total flying hours:
7443
Captain / Total hours on type:
474.00
Copilot / Total flying hours:
788
Copilot / Total hours on type:
242
Aircraft flight hours:
25603
Aircraft flight cycles:
17976
Circumstances:
Following a night takeoff from runway 22R at Sharm el Sheikh-Ophira Airport, the plane climbed and maneuvered for a procedural left turn to intercept the 306 radial from the Sharm el Sheikh VOR station. When the autopilot was engaged the captain made an exclamation and the autopilot was immediately switched off again. The captain then requested Heading Select to be engaged. The plane then began to bank to the right. The copilot then warned the captain a few times about the fact that the bank angle was increasing. At a bank angle of 40° to the right the captain stated "OK come out". The ailerons returned briefly to neutral before additional aileron movements commanded an increase in the right bank. The aircraft had reached a maximum altitude of 5,460 feet with a 50° bank when the copilot stated 'overbank'. Repeating himself as the bank angle kept increasing. The maximum bank angle recorded was 111° right. Pitch attitude at that time was 43° nose down and altitude was 3,470 feet. The observer on the flight deck, a trainee copilot, called 'retard power, retard power, retard power'. Both throttles were moved to idle and the airplane gently seemed to recover from the nose-down, right bank attitude. Speed however increased, causing an overspeed warning. At 04:45 the airplane struck the surface of the water in a 24° right bank, 24° nose-down, at a speed of 416 kts and with a 3,9 G load. The aircraft disintegrated on impact and debris sank by a depth of 900 metres. All 148 occupants were killed, among them 133 French citizens, one Moroccan, one Japanese and 13 Egyptian (all crew members, among them six who should disembark at Cairo). Weather at the time of accident was good with excellent visibility, outside temperature of 17° C and light wind. On January 17, the FDR was found at a depth of 1,020 metres and the CVR was found a day later at a depth of 1,050 metres.
Probable cause:
No conclusive evidence could be found from the findings gathered through this investigation to determine the probable cause. However, based on the work done, it could be concluded that any combination of these findings could have caused or contributed to the accident. Although the crew at the last stage of this accident attempted to correctly recover, the gravity upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Possible causes:
- Trim/Feel Unit Fault (Aileron Trim Runaway),
- Temporarily, Spoiler wing cable jam (Spoiler offset of the neutral position),
- Temporarily, F/O wheel jam (Spoilers offset of the neutral position),
- Autopilot Actuator Hardover Fault.
Possible contributing factors:
- A distraction developing to Spatial Disorientation (SD) until the time the F/O announced 'A/C turning right' with acknowledgment of the captain,
- Technical log copies were kept on board with no copy left at departure station,
- Operator write up of defects was not accurately performed and resulting in unclear knowledge of actual technical status,
- There are conflicting signals which make unclear whether the captain remained in SD or was the crew unable to perceive the cause that was creating an upset condition until the time when the F/O announced that there was no A/P in action,
- After the time then the F/O announced 'no A/P commander' the crew behavior suggests the recovery attempt was consistent with expected crew reaction, evidences show that the corrective action was initiated in full, however the gravity of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Additional findings:
- The ECAA authorization for RAM B737 simulator was issued at a date later than the date of training for the accident crew although the inspection and acceptance test were carried out at an earlier date.
- Several recorded FDR parameters were unreliable and could not be used for the investigation.
Final Report:

Crash of a Boeing 727-223 in Cotonou: 141 killed

Date & Time: Dec 25, 2003 at 1459 LT
Type of aircraft:
Operator:
Registration:
3X-GDO
Flight Phase:
Survivors:
Yes
Schedule:
Conakry - Cotonou - Kufra - Beirut - Dubai
MSN:
21370
YOM:
1977
Flight number:
GIH141
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
153
Pax fatalities:
Other fatalities:
Total fatalities:
141
Captain / Total flying hours:
11000
Captain / Total hours on type:
8000.00
Aircraft flight hours:
67186
Aircraft flight cycles:
40452
Circumstances:
Flight GIH 141 was a weekly scheduled flight, performed by the Union des Transports Africains (UTA), between Conakry (Guinea), Cotonou (Benin), Beirut (Lebanon) and Dubai (United Arab Emirates). A stopover at Kufra (Libya) was planned between Cotonou and Beirut. Having departed from Conakry at 10 h 07 with eighty-six passengers, including three babies, and ten crew members, the Boeing 727-223 registered 3X-GDO landed at Cotonou Cadjèhoun on 25 December 2003 at 12 h 25. Nine passengers disembarked. Sixty-three persons, including two babies, checked in at the airport check-in desk. Ten others, including one baby, boarded from an aircraft that had arrived from Lomé (Togo). Passenger boarding and baggage loading took place in a climate of great confusion. The airplane was full. In the cockpit, two UTA executives were occupying the jump seats. Faced with the particularly large number and size of the hand baggage, the chief flight attendant informed the Captain of the situation. The ground handling company’s agents began loading the baggage in the aft hold when one of the operator’s agents, who remains unidentified, asked them to continue loading in the forward hold, which already contained baggage. When the operation was finished, the hold was full. During this time, the crew prepared the airplane for the second flight segment. The co-pilot was discussing his concerns with the UTA executives, reminding them of the importance of determining the precise weight of the loading of the airplane. The flight plan for Kufra, signed by the Captain, was filed with the ATC office but the meteorological dossier that had been prepared was not collected. Fuel was added to fill up the airplane’s tanks (14,244 liters, or 11.4 metric tons). The accompanying mechanics added some oil. The Captain determined the limitations for the flight and selected the following configuration: flaps 25°, air conditioning units shut down. At 13 h 47 min 55, the crew began the pre-flight checklist. Calm was restored in the cockpit. At 13 h 52 min 12, flight GIH 141 was cleared to roll. The co-pilot was pilot flying (PF). The elevator was set at 6 ¾, it was stated that the takeoff would be performed with full power applied with brakes on, followed by a climb at three degrees maximum to gain speed, with no turn after landing gear retraction. As the roll was beginning, a flight attendant informed the cockpit that passengers who wanted to sit near their friends were still standing and did not want to sit down. The airline’s Director General called the people in the cabin to order. Take-off thrust was requested at 13 h 58 min 01, brake release was performed at 13 h 58 min 15. The airplane accelerated. In the tower, the assistant controller noted that the take-off roll was long, though he did not pay any particular attention to it. At 13 h 59, a speed of a hundred and thirty-seven knots was reached. The Captain called out V1 and Vr. The co-pilot pulled back on the control column. This action initially had no effect on the airplane’s angle of attack. The Captain called « Rotate, rotate »; the co-pilot pulled back harder. The angle of attack only increased slowly. When the airplane had hardly left the ground, it struck the building containing the localizer on the extended runway centerline, at 13 h 59 min 11. The right main landing gear broke off and ripped off a part of the underwing flaps on the right wing. The airplane banked slightly to the right and crashed onto the beach. It broke into several pieces and ended up in the ocean. The two controllers present in the tower heard the noise and, looking in the direction of the takeoff, saw the airplane plunge towards the ground. Immediately afterwards, a cloud of dust and sand prevented anything else being seen. The fire brigade duty chief stated that the airplane seemed to have struck the localizer building. The firefighters went to the site and noticed the damage to the building and the presence of a casualty, a technician who was working there during the takeoff. Noticing some aircraft parts on the beach, they went there through a service gate beyond the installations. Some survivors were still in the wreckage, others were in the water or on the beach. Some inhabitants from the immediate vicinity crowded around, complicating the rescuers’ task. The town fire brigade, the Red Cross and the Cotonou SAMU, along with some members of the police, arrived some minutes later.
Probable cause:
The accident resulted from a direct cause:
• The difficulty that the flight crew encountered in performing the rotation with an overloaded airplane whose forward center of gravity was unknown to them; and two structural causes:
• The operator’s serious lack of competence, organization and regulatory documentation, which made it impossible for it both to organize the operation of the route correctly and to check the loading of the airplane;
• The inadequacy of the supervision exercised by the Guinean civil aviation authorities and, previously, by the authorities in Swaziland, in the context of safety oversight.
The following factors could have contributed to the accident:
• The need for air links with Beirut for the large communities of Lebanese origin in West Africa;
• The dispersal of effective responsibility between the various actors, in particular the role played by the owner of the airplane, which made supervision complicated;
• The failure by the operator, at Conakry and Cotonou, to call on service companies to supply information on the airplane’s loading;
• The Captain’s agreement to undertake the take-off with an airplane for which he had not been able to establish the weight;
• The short length of the runway at Cotonou;
• The time of day chosen for the departure of the flight, when it was particularly hot;
• The very wide margins, in particular in relation to the airplane’s weight, which appeared to exist, due to the use of an inappropriate document to establish the airplane’s weight and balance sheet;
• The existence of a non-frangible building one hundred and eighteen meters after the runway threshold.
Final Report: