Crash of a Boeing 727-22 in Kisangani: 77 killed

Date & Time: Jul 8, 2011 at 1511 LT
Type of aircraft:
Operator:
Registration:
9Q-COP
Survivors:
Yes
Schedule:
Kinshasa - Kisangani - Goma
MSN:
18933/185
YOM:
1965
Flight number:
EO952
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
77
Captain / Total flying hours:
7000
Captain / Total hours on type:
5000.00
Aircraft flight hours:
52613
Circumstances:
Following an uneventful flight from Kinshasa, the crew started the descent to Kisangani-Bangoka Airport in poor weather conditions with low visibility due to heavy rain falls. On final approach, the pilot did not establish any visual contact with the runway but continued until the aircraft impacted ground some 1,000 metres short of runway 31. On impact, the aircraft went out of control, veered to the right, exploded and disintegrated in a wooded area located to the right of the approach path. The wreckage was found about 500 metres southeast from the runway 31 threshold. Five crew and 72 passengers were killed.
Probable cause:
In a preliminary report, DRC authorities pointed out the following factors:
- The flight crew misjudged weather conditions,
- The airline assigned unqualified/non-licensed crew to operate the Boeing 727-100 (the pilot's licence was not up to date),
- Tower controllers were not licensed (two ATC's did not have a proper licence and above legal age)
- Tower control staff was insufficient (six only for the complete roster),
- Tower controllers provided erroneous/false weather data to flying crew,
- The airport authority lacked security plans,
- Phonic records between tower control and crew were erased (destroyed) before the commission of inquiry can start any investigation.

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

Date & Time: Jul 4, 2011 at 1610 LT
Type of aircraft:
Operator:
Registration:
C-FMCB
Flight Phase:
Survivors:
Yes
Schedule:
Pukatawagan - The Pas
MSN:
208B-1114
YOM:
2005
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1900
Captain / Total hours on type:
400.00
Circumstances:
The Beaver Air Services Limited Partnership Cessna 208B (registration C-FMCB serial number 208B1114), operated by its general partner Missinippi Management Ltd (Missinippi Airways), was departing Pukatawagan, Manitoba, for The Pas/Grace Lake Airport, Manitoba. At approximately 1610 Central Daylight Time, the pilot began the takeoff roll from Runway 33. The aircraft did not become fully airborne, and the pilot rejected the takeoff. The pilot applied reverse propeller thrust and braking, but the aircraft departed the end of the runway and continued down an embankment into a ravine. A post-crash fire ensued. One of the passengers was fatally injured; the pilot and the 7 other passengers egressed from the aircraft with minor injuries. The aircraft was destroyed. The emergency locator transmitter did not activate.
Probable cause:
Findings as to Causes and Contributing Factors:
Runway conditions, the pilot's takeoff technique, and possible shifting wind conditions combined to reduce the rate of the aircraft's acceleration during the takeoff roll and prevented it from attaining takeoff airspeed. The pilot rejected the takeoff past the point from which a successful rejected takeoff could be completed within the available stopping distance. The steep drop-off and sharp slope reversal at the end of Runway 33 contributed to the occupant injuries and fuel system damage that in turn caused the fire. This complicated passenger evacuation and prevented the rescue of the injured passenger. The deceased passenger was not wearing the available shoulder harness. This contributed to the serious injuries received as a result of the impact when the aircraft reached the bottom of the ravine and ultimately to his death in the post-impact fire.
Findings as to Risk:
If pilots are not aware of the increased aerodynamic drag during takeoff while using soft-field takeoff techniques they may experience an unexpected reduction in takeoff performance. Incomplete passenger briefings or inattentive passengers increase the risk that they will be unable to carry out critical egress procedures during an aircraft evacuation. When data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety. Although the runway at Pukatawagan and many other aerodromes are compliant with Aerodrome Standards and Recommended Practices (TP 312E), the topography of the terrain beyond the runway ends may increase the likelihood of damage to aircraft and injuries to crew and passengers in the event of an aircraft overrunning or landing short. TC's responses to TSB recommendations for action to reduce the risk of post-impact fires have been rated as Unsatisfactory. As a result, there is a continuing risk of post-impact fires in impact-survivable accidents involving these aircraft. The lack of accelerate stop distance information for aircraft impedes the crew's ability to plan the takeoff-reject point accurately.
Other finding:
Several anomalies were found in the engine's power control hardware. There was no indication that these anomalies contributed to the occurrence.
Final Report:

Crash of a Tupolev TU-134A-3 in Petrozavodsk: 47 killed

Date & Time: Jun 20, 2011 at 2340 LT
Type of aircraft:
Operator:
Registration:
RA-65691
Survivors:
Yes
Schedule:
Moscow - Petrozavodsk
MSN:
63195
YOM:
1980
Flight number:
CGI9605
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
8501
Captain / Total hours on type:
3158.00
Copilot / Total flying hours:
2846
Copilot / Total hours on type:
1099
Aircraft flight hours:
35591
Aircraft flight cycles:
20977
Circumstances:
Aircraft left Moscow-Domodedovo Airport in 2224LT for Petrozavodsk, Karelia. On final approach by night and fog reducing vertical visibility to 300 metres, crew descended too low without a visual contact was established with the runway lights. Aircraft descended below the MDA, hit an electric pole, crashed on a road and came to rest in a garden, 570 metres short of runway 02. Eight people were rescued as all other 44 occupants were killed. Flight was operated by RusAir on behalf of RusLine (flight 243). Russian FIFA's football referee Vladimir Pettaï was also killed in this accident. Two days later, a survivor died from his injuries. The weekend following the accident (five days and six days later), two survivors died from their injuries (burns).
Probable cause:
When the aircraft approached the airfield in weather below minimums for the aerodrome descending on autopilot at a fixed vertical speed, crew failed to decide to go around in absence of visual contact with approach lights and landmarks and permitted the aircraft to descend below minimum descent altitude, which led to impact with trees and the ground in controlled flight.
Following factors were considered as contirbutory:
- unsatisfactory crew resource management by the commander who effectively removed the first officer from the control loop in the final stages of the accident flight and who subordinated himself to the navigator showing increased activity however in the state of mild alcoholic intoxication.
- the navigator was in the state of mild alcoholic intoxication
- unjustified weather forecasts by height of cloud base, visibility and severe weather including fog as well as the non-conformity of weather data of Petrozavodsk Airport transmitted to the crew 30 and 10 minutes prior to estimated landing.
- Failure to use indications by the ADFs and other devices of the aircraft while using indications by an unapproved satellite navigation system KLN-90 in violation of flight manual supplements for the TU-134.
Final Report:

Crash of a Dassault Falcon 10 in Toronto

Date & Time: Jun 17, 2011 at 1506 LT
Type of aircraft:
Operator:
Registration:
C-GRIS
Flight Type:
Survivors:
Yes
Schedule:
Toronto-Lester Bowles Pearson - Toronto-Buttonville
MSN:
02
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
7100
Copilot / Total hours on type:
475
Aircraft flight hours:
12697
Circumstances:
Aircraft was on a flight from Toronto-Lester B. Pearson International Airport to Toronto-Buttonville Municipal Airport, Ontario, with 2 pilots on board. Air traffic control cleared the aircraft for a contact approach to Runway 33. During the left turn on to final, the aircraft overshot the runway centerline. The pilot then compensated with a tight turn to the right to line up with the runway heading and touched down just beyond the threshold markings. Immediately after touchdown, the aircraft exited the runway to the right, and continued through the infield and the adjacent taxiway Bravo, striking a runway/taxiway identification sign, but avoiding aircraft that were parked on the apron. The aircraft came to a stop on the infield before Runway 21/03. The aircraft remained upright, and the landing gear did not collapse. The aircraft sustained substantial damage. There was no fire, and the flight crew was not injured. The Toronto-Buttonville tower controller observed the event as it progressed and immediately called for emergency vehicles from the nearby municipality. The accident occurred at 1506 Eastern Daylight Time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew flew an unstabilized approach with excessive airspeed.
2. The lack of adherence to company standard operating procedures and crew resource management, as well as the non-completion of checklist items by the flight crew contributed to the occurrence.
3. The captain’s commitment to landing or lack of understanding of the degree of instability of the flight path likely influenced the decision not to follow the aural GPWS alerts and the missed approach call from the first officer.
4. The non-standard wording and the tone used by the first officer were insufficient to deter the captain from continuing the approach.
5. At touchdown, directional control was lost, and the aircraft veered off the runway with sufficient speed to prevent any attempts to regain control.
Finding as to Risk
1. Companies which do not have ground proximity warning system procedures in their standard operating procedures may place crews and passengers at risk in the event that a warning is received.
Final Report:

Mishap of a Beechcraft A100 King Air in Blountville

Date & Time: Jun 15, 2011 at 1405 LT
Type of aircraft:
Operator:
Registration:
N15L
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bridgewater - Wichita
MSN:
B-212
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4837
Captain / Total hours on type:
87.00
Copilot / Total flying hours:
900
Copilot / Total hours on type:
2
Aircraft flight hours:
16170
Circumstances:
The airplane was flying in instrument meteorological conditions at flight level 200 (about 20,000 feet), and a large area of thunderstorm activity was located to the northwest. About 20 miles from the thunderstorm activity, the airplane began to encounter moderate turbulence and severe icing conditions. The pilot deviated to the south; however, the turbulence increased, and the airplane entered an uncommanded left roll and dive. The autopilot disengaged, and the pilot's attitude indicator dropped. The pilot leveled the airplane at an altitude of 8,000 feet and landed without further incident. Subsequent examination revealed that one-third of the outboard left elevator separated in flight and that the empennage was substantially damaged. Meteorological and radar data revealed the airplane entered an area of rapidly intensifying convective activity, which developed along the airplane's flight path, and likely encountered convectively-induced turbulence with a high probability of significant icing. The effect of icing conditions on the initiation of the upset could not be determined; however, airframe structural icing adversely affects an airplane's performance and can result in a loss of control.
Probable cause:
An encounter with convectively-induced turbulence and icing, which resulted in an in-flight upset and a loss of airplane control.
Final Report:

Crash of a Boeing B-17G-105-VE Flying Fortress in Aurora

Date & Time: Jun 13, 2011 at 0947 LT
Registration:
N390TH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aurora - Aurora
MSN:
8643
YOM:
1944
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The weekend before the accident, a fuel leak was identified. The fuel leak was subsequently repaired, and a final inspection the morning of the accident flight reportedly did not reveal any evidence of a continued fuel leak. Shortly after takeoff, the flight crew noticed a faint odor in the cockpit and a small amount of smoke near the radio room. The flight crew immediately initiated a turn with the intention of returning to the departure airport. About that time, they received a radio call from the pilot of the accompanying airplane advising that there was a fire visible on the left wing. The accident pilot subsequently executed an emergency landing to a corn field. Emergency crews were hampered by the muddy field conditions, and the fire ultimately consumed significant portions airframe. In-flight photographs showed the presence of fire on the aft lower portion of the left wing between the inboard and outboard engines. Located in the same area of the fire were fuel tanks feeding the left-side engines. After landing, heavy fire conditions were present on the left side of the airplane, and the fire spread to the fuselage. A postaccident examination noted that the C-channel installed as part of the No. 1 main fuel tank repair earlier in the week was partially separated. During the examination, the tank was filled with a small amount of water, which then leaked from the aft section of the repair area in the vicinity of the partially separated channel. Metallurgical examination of the repair area revealed a longitudinal fatigue crack along the weld seam. The fatigue nature of the crack was consistent with a progressive failure along the fuel tank seam that existed before the accident flight and was separate from the damage sustained in the emergency landing and postlanding fire. The repair earlier in the week attempted to seal the leak but did not address the existing crack itself. In fact, the length of the crack observed at the time of the repair was about one-half the length of the crack noted during the postaccident examination, suggesting that the crack progressed rapidly during the course of the accident flight. Because the repaired fuel tank was positioned within the open wing structure, a fuel leak of significant volume would have readily vaporized, producing a flammable fuel vapor/air mixture. Although the exact ignition source could not be determined due to the fire damage, it is likely that the fuel vapor and liquid fuel encountered hot surfaces from nearby engine components, which initiated the in-flight fire.
Probable cause:
An inadequate repair of the fuel tank that allowed the fuel leak to continue, ultimately resulting in an inflight fire.
Final Report:

Crash of a Douglas DC-6BF in Cold Bay

Date & Time: Jun 12, 2011 at 1455 LT
Type of aircraft:
Operator:
Registration:
N600UA
Flight Type:
Survivors:
Yes
Schedule:
Togiak - Cold Bay
MSN:
44894/651
YOM:
1956
Location:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
4000.00
Aircraft flight hours:
37334
Circumstances:
According to the captain, while on approach to land, he distracted the crew by pointing out a boat dock. He said that after touchdown, he realized that the landing gear was not extended, and the airplane slid on its belly, sustaining substantial damage to the underside of the fuselage. He said that the crew did not hear the landing gear retracted warning horn, and the accident could have been prevented if he had not distracted the crew. The captain reported that there were no mechanical malfunctions with the airplane that would have precluded normal operation.
Probable cause:
The flight crew's failure to extend the landing gear, which resulted in an inadvertent wheels up landing. Contributing to the accident was the flight crew's diverted attention.
Final Report:

Crash of an Eclipse EA500 in Nome

Date & Time: Jun 1, 2011 at 2140 LT
Type of aircraft:
Registration:
N168TT
Flight Type:
Survivors:
Yes
Schedule:
Anadyr – Nome
MSN:
42
YOM:
2007
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2370
Captain / Total hours on type:
205.00
Aircraft flight hours:
343
Circumstances:
The pilot indicated that, prior to the accident flight, the wing flaps had failed, but he decided to proceed with the flight contrary to the Airplane Flight Manual guidance. While conducting a no-flap approach to the airport, he decided that his airspeed was too fast to land, and he initiated a go-around. During the go-around, the airplane continued to descend, and the fuselage struck the runway. The pilot was able to complete the go-around, and realized that he had not extended the landing gear. He lowered the landing gear, and landed the airplane uneventfully. He elected to remain overnight at the airport due to fatigue. The next day, he decided to test fly the airplane. During the takeoff roll, the airplane had a severe vibration, and he aborted the takeoff. During a subsequent inspection, an aviation mechanic discovered that the center wing carry-through cracked when the belly skid pad deflected up into a stringer during the gear-up landing.
Probable cause:
The pilot landed without lowering the landing gear. Contributing to the accident was the pilot's decision to fly the airplane with an inoperative wing flap system.
Final Report:

Crash of a North American B-25J-35-NC Mitchell in Melun

Date & Time: May 31, 2011 at 1730 LT
Registration:
F-AZZU
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Melun - Melun
MSN:
108-47562
YOM:
1944
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crew was performing a local flight at Melun-Villaroche Airport. Few minutes after takeoff, while flying at low height, the engine caught fire. The pilot elected to return to the airport but was eventually forced to attempt an emergency landing. The aircraft collided with power cables then crashed on its belly in a field, coming to rest in flames. Both occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
The right engine caught fire in flight for unknown reasons.

Crash of an Embraer EMB-500 Phenom 100 in Sedona

Date & Time: May 25, 2011 at 1550 LT
Type of aircraft:
Operator:
Registration:
N224MD
Survivors:
Yes
Schedule:
San Jose - Sedona
MSN:
500-00057
YOM:
2009
Flight number:
RSP240
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23970
Captain / Total hours on type:
570.00
Copilot / Total flying hours:
1886
Copilot / Total hours on type:
74
Aircraft flight hours:
1052
Circumstances:
Following an uneventful flight, the flight crew briefed the arrival to the destination airport and set the calculated landing speeds. The captain and the first officer reported that during final approach, it felt like the airplane was “pushed up” as the wind shifted to a tailwind or updraft before landing near the runway number markings. Upon touchdown, the captain applied the brakes and thought that the initial braking was effective; however, he noticed the airplane was not slowing down. The captain applied maximum braking, and the airplane began to veer to the right; he was able to correct back to the runway centerline, but the airplane subsequently exited the departure end of the runway and traveled down a steep embankment. A pilot-rated passenger reported that throughout the approach to landing, he thought the airplane was high and thought that the excessive altitude continued through and into the base-to-final turn. He added that the bank angle of this turn seemed greater than 45 degrees. Recorded communication from the cockpit voice and data recorder (CVDR) revealed that during the approach to landing, the flight crew performed the landing checks, and the captain noted difficulty judging the approach. About 1 minute later, the recording revealed that the ground warning proximity system reported “five hundred” followed by a “sink rate, pull up” alert about 16 seconds later. Data from the CVDR revealed that about 23 seconds before weight-on-wheels was recorded, the airplane was at an indicated airspeed of about 124 knots and descending. The data showed that this approximate airspeed was maintained until about 3 seconds before weight-on-wheels. The recorded data further showed that the approach speed was set to 120 knots, and the landing reference speed (vREF) was set to 97 knots. Using the reported airplane configuration and the 3.5-knot headwind that was reported at the time of the approach and landing, calculations indicate that the vREF speed should have been about 101 knots indicated airspeed, which would have required a landing distance of about 3,112 feet. Utilizing the same airplane configuration and wind condition with the flight’s reported 124 knot indicated airspeed just before touchdown, the landing distance was calculated to be about 5,624 feet. The intended runway for landing was 5,132-feet long with a 1.9 percent downward slope gradient, and a 123-foot long overrun area. A postaccident examination of the airplane, including the braking system, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot misjudged the airplane’s speed during the final approach, which resulted in runway overrun.
Probable cause:
The pilots’ unstabilized approach and excessive airspeed during approach, which resulted in an insufficient landing distance to stop the airplane before overrunning the runway.
Final Report: