Airport (less than 10 km from airport)

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Schedule:

Val d'Or - Chicoutimi

MSN:

B-215

YOM:

1975

Flight number:

ET822

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

3500

Captain / Total hours on type:

1000.00

Copilot / Total flying hours:

1000

Copilot / Total hours on type:

150

Circumstances:

The Beechcraft was on an instrument flight rules flight between Val-d’Or and Chicoutimi/Saint-Honoré, Quebec, with 2 pilots and 2 passengers on board. At 2240 Eastern Standard Time, the aircraft was cleared for an RNAV (GNSS) Runway 12 approach and switched to the aerodrome traffic frequency. At 2250, the International satellite system for search and rescue detected the aircraft’s emergency locator transmitter signal. The aircraft was located at 0224 in a wooded area approximately 3 nautical miles from the threshold of Runway 12, on the approach centreline. Rescuers arrived on the scene at 0415. The 2 pilots were fatally injured, and the 2 passengers were seriously injured. The aircraft was destroyed on impact; there was no post-crash fire.

Probable cause:

Findings as to Causes and Contributing Factors:
For undetermined reasons, the crew continued its descent prematurely below the published approach minima, leading to a controlled flight into terrain (CFIT).
Findings as to Risk:
1. The use of the step-down descent technique rather than the stabilized constant descent angle (SCDA) technique for non-precision instrument approaches increases the risk of an approach and landing accident (ALA).
2. The depiction of the RNAV (GNSS) Runway 12 approach published in the Canada Air Pilot (CAP) does not incorporate recognized visual elements for reducing ALAs, as recommended in Annex 4 to the Convention, thereby reducing awareness of the terrain.
3. The installation of a terrain awareness warning system (TAWS) is not yet a requirement under the Canadian Aviation Regulations (CARs) for air taxi operators. Until the changes to regulations are put into effect, an important defense against ALAs is not available.
4. Most air taxi operators are unaware of and have not implemented the FSF ALAR task force recommendations, which increases the risk of a CFIT accident.
5. Approach design based primarily on obstacle clearance instead of the 3° optimum angle increases the risk of ALAs.
6. The lack of information on the SCDA technique in Transport Canada reference manuals means that crews are unfamiliar with this technique, thereby increasing the risk of ALAs.
7. Use of the step-down descent technique prolongs the time spent at minimum altitude, thereby increasing the risk of ALAs.
8. Pilots are not sufficiently educated on instrument approach procedure design criteria. Consequently, they tend to use the CAP published altitudes as targets, and place the aircraft at low altitude prematurely, thereby increasing the risk of an ALA.
9. Where pilots do not have up-to-date information on runway conditions needed to check runway contamination and landing distance performance, there is an increased risk of landing accidents.
10. Non-compliance with instrument flight rules (IFR) reporting procedures at uncontrolled airports increases the risk of collision with other aircraft or vehicles.
11. If altimeter corrections for low temperature and remote altimeter settings are not accurately applied, obstacle clearance will be reduced, thereby increasing the CFIT risk.
12. When cockpit recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.
13. Task-induced fatigue has a negative effect on visual and cognitive performance which can diminish the ability to concentrate, operational memory, perception and visual acuity.
14. Where an emergency locator transmitter (ELT) is not registered with the Canadian Beacon Registry, the time needed to contact the owner or operator is increased which could affect occupant rescue and survival.
15. If the tracking of a call to 911 emergency services from a cell phone is not accurate, search and rescue efforts may be misdirected or delayed which could affect occupant rescue and survival.
Other Findings:
1. Weather conditions at the alternate airport did not meet CARs requirements, thereby reducing the probability of a successful approach and landing at the alternate airport if a diversion became necessary.
2. Following the accident, none of the aircraft exits were usable.

Final Report:

Crash of a Beechcraft F90 King Air in Egelsbach: 3 killed

Date & Time: Dec 7, 2009 at 1616 LT

Type of aircraft:

Beechcraft 90 King Air

Operator:

Registration:

D-IDVK

Flight Phase:

Executive/Corporate/Business

Flight Type:

Survivors:

Site:

Schedule:

Bremen - Egelsbach

MSN:

LA-96

YOM:

1981

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2200

Aircraft flight hours:

6069

Aircraft flight cycles:

5353

Circumstances:

On a flight from Bremen (EDDW) to Frankfurt-Egelsbach (EDFE), a Beechcraft King Air (F90) changed from IFR to VFR rules prior to the final approach, during which it collided with trees, crashing in a wood and catching fire. On board were the pilot and two passengers. The right hand cockpit seat was occupied by a passenger who conducted radio communications. The approach to runway 27 at EDFE was chosen and executed via the so-called High Performance Aircraft Approach (HPA-approach) as published in the Aeronautical Information Publication (AIP). From 1558 hrs onwards the aircraft was under control by Langen Radar (120.8 MHz), and radar contact was confirmed by the controller. After about six minutes the controller issued the instruction: “[call sign], report if able to cancel IFR”. Subsequently, further instructions were issued to descend to altitude 5,000 ft on QNH 1,012 hPa and fly towards Egelsbach entry point Hotel 1. About four minutes later the controller gave instructions to descend to 4,000 ft, then 3,000 ft. Simultaneously, clearance was given to fly from entry point Hotel 1 to Hotel 2 and then Hotel 3. When overhead entry point Hotel 2 at 1613 hrs, the King Air reported flight conditions as ‘Victor Mike Charlie’ (VMC – Visual Meteorological Conditions) and the switch to VFR (Visual Flight Rules). At this time, the radar recorded the aircraft’s ground speed as about 180 kt. Langen Radar confirmed the report and gave an instruction to continue the descent and report passing 1,500 ft. About 42 seconds later the pilot was instructed to contact Egelsbach Info (130.9 MHz). The radar trace indicated that at this time the aircraft was at an altitude of about 1,800 ft and about 5.5 NM from the airfield. The ground speed was about 180 kt. The first radio call from the Beech to Egelsbach Info took place about 15 seconds later at 1615:06 hrs, at an altitude of about 1,500 ft and ground speed of about 190 kt. Egelsbach Info gave the information that the aircraft was north of the approach centreline and asked for a course correction to the left. They further reported the wind as Easterly at 4 knots with Runway 27 in use. After the response “[call sign], thank you” Egelsbach Info responded: “lights and flashes are on“. During the subsequent approach, the aircraft ground speed reduced over a distance of about 1.3 NM from about 190 kt to about 130 kt (distance to aerodrome about 3 NM). The radar trace indicates that from a position of 3.7 NM from the aerodrome to 2.5 NM from the aerodrome, the aircraft descended from 1,500 ft to 1,000 ft.At about 1616:03 hrs Egelsbach Info advised: “[…]coming up onto centreline”. This was acknowledged with “[call sign]”, following which Egelsbach Info advised: “you are now on centreline”. This was acknowledged with “thank you very much“. The radar trace indicates that at this time the aircraft descended from 900 ft to 800 ft. When Egelsbach Info advised “check your altitude”, the aircraft was at an altitude of about 800 ft. After a further two seconds, at 1616:18 hrs, the radar data indicated the aircraft height as about 700 ft; there was no more indication on the radar screen afterwards. In this area, the terrain is about 620 ft, with trees extending to about 700 ft AMSL. At 1616:24 hrs the aircraft was requested by Egelsbach Info to alter course slightly to the right. Neither a reply was received to this request nor to a subsequent transmission from Egelsbach Info about 22 seconds later. Egelsbach Info assumed there had been a crash and alerted the emergency services, the first of which arrived at the accident site at about 1638 hrs and found a burning wreck.

Probable cause:

The accident was caused by the descent during final approach which led into a fog layer and obstacles.
Contributing factors were:
- A too high descent rate
- An impaired performance and an insufficient situational awareness favored by the intake of alcohol
- That no visual contact with the PAPI or airfield was established
- That the on-board aids to navigation were not or not sufficiently used.

Final Report:

Crash of an Embraer 135 in George

Date & Time: Dec 7, 2009 at 1101 LT

Type of aircraft:

Embraer ERJ-135

Operator:

Registration:

ZS-SJW

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Cape Town - George

MSN:

145-423

YOM:

2001

Flight number:

SA8625

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11973

Captain / Total hours on type:

2905.00

Copilot / Total flying hours:

2336

Copilot / Total hours on type:

864

Aircraft flight hours:

21291

Aircraft flight cycles:

17003

Circumstances:

Flight SA8625 departed from Cape Town International Airport on a domestic scheduled flight to George Airport (FAGG) with three crew members and 32 passengers on board. The weather at FAGG was overcast with light rain, and the aircraft was cleared for an instrument landing system approach for runway 11. It touched down between the third and fourth landing marker. According to the air traffic controller, the landing itself appeared normal, but the aircraft did not vacate the runway to the left as it should have. Instead, it veered to the right, overran the runway and rolled on past the ILS localiser. Realising that something was wrong, he activated the crash alarm. The cockpit crew did not broadcast any messages to indicate that they were experiencing a problem. The aircraft collided with eleven approach lights before bursting through the aerodrome perimeter fence and coming to rest in a nose-down attitude on the R404 public road. Several motorists stopped and helped the passengers, who evacuated the aircraft through the service door (right front) and left mid-fuselage emergency exit. The aerodrome fire and rescue personnel arrived within minutes and assisted with the evacuation of the cockpit crew, who were trapped in the cockpit. Ten occupants were admitted to a local hospital for a check-up and released after a few hours. No serious injuries were reported.

Probable cause:

The crew were unable to decelerate the aircraft to a safe stop due to ineffective braking of the aircraft on a wet runway surface, resulting in an overrun.
Contributory factors:
- The aircraft crossed the runway threshold at 50 ft AGL at 143 KIAS, which was 15 kt above the calculated VREF speed.
- Although the aircraft initially touched down within the touchdown zone the transition back into air mode of 1.5 seconds followed by a 4 second delay in applying the brakes after the aircraft remained in permanent ground mode should be considered as a significant contributory factor to this accident as it was imperative to decelerate the aircraft as soon as possible.
- Two of the four main tyres displayed limited to no tyre tread. This was considered to have degraded the displacement of water from the tyre footprint, which had a significant effect on the braking effectiveness of the aircraft during the landing rollout on the wet runway surface.
Several non-compliance procedures were not followed.

Final Report:

Crash of a Fokker 100 in Kupang

Date & Time: Dec 2, 2009 at 2215 LT

Type of aircraft:

Fokker 100

Operator:

Registration:

PK-MJD

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Ujung Pandang - Kupang

MSN:

11474

YOM:

1993

Flight number:

MZ5840

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

18776

Copilot / Total flying hours:

7074

Aircraft flight hours:

29637

Aircraft flight cycles:

29450

Circumstances:

PK-MJD was on passenger schedule flight from Sultan Hasanuddin Airport, Makassar with destination El Tari Airport, Kupang, East Nusa Tenggara. The flight number was Merpati 5840 and carried 94 person on board consist of 88 passengers including four children and four infants, two pilot and four flight attendant. A maintenance engineer was on-board in this flight. Acting as pilot flying was the Second in Command (SIC) while the Pilot in Command acted as Pilot Monitoring. On approach, the pilot selected landing gear to down position. The left main landing gear indicator light was showed red, its means that the left main landing gear was not in down position and unsafe for landing. The pilot reported to the Air Traffic Controller (ATC) for a go-around and requested an area for holding to solve the problem. The ATC gave a clearance to hold over Kupang bay. The pilot tried to solve the problem by conducting the procedure according to the emergency checklist, including selected the landing gear by alternate selector. The pilot then requested to the ATC to fly at low altitude over the airport and asked to the ATC to observe the landing gear condition. The pilot also asked through the company radio for an engineer on-ground to observe visually the landing gear condition. The pilot then returned to the holding area, repeated the procedure but unsuccessful. Both pilots and engineer had a discussion and decided to attempt un-procedural method to make the landing gear down. Prior making these efforts the pilot announced to the passengers about the problem and their attempts that might be unpleasant to the passengers. After all attempts to lower the landing gear had failed, the pilot decided to land with the left main landing gear in up position. The pilot also asked the flight attendant to prepare for an abnormal landing. The ATC were prepared the airport fire fighting and ambulance, and also contacted the local police, armed forces, and hospitals and asking for additional ambulances. The ATC then informed the pilot that the ground support was ready. On short final the pilot instructed ‘brace for impact’ and the FA repeated that instruction to all passengers. The aircraft touched down at the touch down zone on runway 07. The pilot flying held the left wing as long as possible and kept the aircraft on the centre line, and the pilot monitoring shut down both engines. The aircraft stopped at about 1,200 meters from the beginning of runway 07, on the left shoulder of the runway and the FA instructed to the passengers to keep calm and to evacuate the aircraft. The pilot continued the procedures for emergency. The evacuation was performed through all door and window exits. No one was injured on this serious incident.

Probable cause:

The debris trapped in the chamber between the orifice and the stopper of the restrictor check valve, it caused the orifice closed. This condition was resulted the hydraulic flow from the actuator blocked and caused the left main landing gear jammed at up position.

Final Report:

Ground accident of a Boeing 727-222F in São Paulo

Date & Time: Dec 1, 2009 at 0130 LT

Type of aircraft:

Boeing 727-200

Operator:

Registration:

PR-MTK

Flight Phase:

Taxiing

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Brasília – São Paulo

MSN:

20037/701

YOM:

1969

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Following an uneventful night cargo flight from Brasília, the aircraft landed at São Paulo-Guarulhos Airport. While taxiing, the aircraft hit airport equipment while approaching its stand. The aircraft was severely damaged on its nose and cockpit area. All three occupants escaped uninjured while the aircraft was damaged beyond repair. The encountered brakes problems.

Crash of a McDonnell Douglas MD-11F in Shanghai: 3 killed

Date & Time: Nov 28, 2009 at 0814 LT

Type of aircraft:

McDonnell Douglas MD-11

Operator:

Registration:

Z-BAV

Flight Phase:

Takeoff (climb)

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Shanghai - Bishkek

MSN:

48408/457

YOM:

1990

Flight number:

SMJ324

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The three engine aircraft departed Shanghai-Pudong Airport on a cargo flight to Bishkek, carrying various goods and seven crew members. During the takeoff roll from runway 35L, the pilot-in-command initiated the rotation but the aircraft did not lift off properly with had a negative vario. It overran the runway and eventually crashed in an open field. Three crew were killed while four others were injured. The aircraft was totally destroyed.

Probable cause:

The crew did not properly operate the thrust levers so that the engines did not reach take off thrust. The aircraft had not reached Vr at the end of the runway and could not get airborne. According to the design criteria of the MD11 the crew needs to push at least two thrust levers to beyond 60 degrees, which will trigger autothrust to leave "CLAMP" mode and adjust the thrust to reach the target setting for takeoff, the servo motors would push the thrust levers forward in that case. During the accident departure the pilot in the left seat did not advance the thrust levers to more than 60 degrees, hence the server motors did not work although autothrust was engaged but remained in CLAMP mode and thus did not adjust the thrust to reach takeoff settings. The crew members perceived something was wrong. Audibly the engine sound was weak, visibibly the speed of the aircraft was low, tactically the pressure on the back of the seat was weaker than normal. Somebody within the crew, possibly on the observer seats, suggested the aircraft may be a bit heavy. The T/O THRUST page never appeared (it appears if autothrust is engaged and changes from CLAMP to Thrust Limit setting. Under normal circumstances with autothrust being engaged a click sound will occur as soon as the thrust levers reach the takeoff thrust position. A hand held on the thrust levers will feel the lever moving forward, however, the crew entirely lost situational awareness. None of the anomalies described in this paragraph prompted the crews members' attention. When the aircraft approached the end of the runway several options were available: reject takeoff and close the throttles, continue takeoff and push the throttle to the forward mechanical stop, continue takeoff and immediately rotate. The observer called "rotate", the captain rotated the aircraft. This shows the crew recognized the abnormal situation but did not identify the error (thrust levers not in takeoff position) in a hurry but reacted instinctively only. As the aircraft had not yet reached Vr, the aircraft could not get airborne when rotated. As verified in simulator verification the decision to rotate was the wrong decision. The simulator verification showed, that had the crew pushed the thrust levers into maximum thrust when they recognized the abnormal situation, they would have safely taken the aircraft airborne 670 meters before the end of the runway. The verification also proved, that had the crew rejected takeoff at that point, the aircraft would have stopped before the end of the runway. The crew did not follow standard operating procedures for managing thrust on takeoff. The crew operations manual stipulates that the left seat pilot advances the thrust levers to EPR 1.1 or 70% N1 (depending on engine type), informs the right seat pilot to connect autothrust. The pilot flying subsequently pushes the thrust levers forward and verifies they are moving forward on servos, the pilot monitoring verifies autothrust is working as expected and reaches takeoff thrust settings. In this case the left seat pilot not only did not continue to push the thrust levers forward, but also called out "thrust set" without reason as he did not verify the takeoff thrust setting had been achieved. It is not possible to subdivide the various violations of procedures and regulations. The crew had worked 16 hours during the previous sector. In addition, one crew member needed to travel for 11 hours from Europe to reach the point of departure of the previous sector (Nairobi Kenya), two crew members need to travel for 19 hours from America to the point of departure of the previous sector. These factors caused fatigue to all crew members. The co-pilot was 61 years of age, pathological examination showed he was suffering from hypertension and cardiovascular atherosclerosis. His physical strength and basic health may have affected the tolerance towards fatigue. All crew members underwent changes across multiple time zones in three days. Although being in the period of awakeness in their biological rhythm cycle, the cycle was already in a trough period causing increased fatigue. The captain had flown the Airbus A340 for 300 hours in the last 6 months, which has an entirely different autothrust handling, e.g. the thrust levers do not move with power changes in automatic thrust, which may have caused the captain to ignore the MD-11 thrust levers. The co-pilot in the right hand seat had been MD-11 captain for about 7 years but had not flown the MD-11 for a year. Both were operating their first flight for the occurrence company. The two pilots on the observer seats had both 0 flight hours in the last 6 months. The co-pilot (right hand seat) was pilot flying for the accident sector. The captain thus was responsible for the thrust management and thrust lever movement according to company manual. A surviving observer told the investigation in post accident interviews that the captain was filling out forms and failed to monitor the aircraft and first officer's actions during this critical phase of flight. There are significant design weaknesses in the MD-11 throttle, the self checks for errors as well as degree of automation is not high.
Source: Aviation Herald/Simon Hradecky

Crash of a Lockheed KC-130J Hercules in Pisa: 5 killed

Date & Time: Nov 23, 2009 at 1410 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

MM62176

Flight Phase:

Takeoff (climb)

Flight Type:

Training

Survivors:

Site:

Pisa-San Giusto-Galileo Galilei (Arturo dell'Oro)

Schedule:

Pisa - Pisa

MSN:

5497

YOM:

2000

Location:

Tuscany

Country:

Italy

Region:

Europe

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

Shortly after takeoff from Pisa-San Giusto-Galileo Galilei Airport, while climbing, the four engine aircraft went out of control and crashed on a railway road located 3 km southwest of the airfield. The aircraft was destroyed by impact forced and a post crash fire and all five occupants from the 46th Squadron were killed.

Crash of a McDonnell Douglas MD-82 in Goma

Date & Time: Nov 19, 2009 at 1100 LT

Type of aircraft:

McDonnell Douglas MD-82

Operator:

Registration:

9Q-CAB

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Democratic Republic of Congo

Schedule:

Kinshasa - Goma

MSN:

49702/1479

YOM:

1988

Flight number:

E93711

Location:

Goma

Nord-Kivu

Country:

Region:

Africa

Crew on board:

Crew fatalities:

Pax on board:

111

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After landing on runway 36 at Goma Airport, the aircraft failed to stop within the remaining distance. It overran and came to rest in a rocky lava field. At least 20 passengers were injured while the aircraft was damaged beyond repair. At the time of the accident, the runway was wet.

Crash of a Cessna 208B Grand Caravan in Windhoek: 3 killed

Date & Time: Nov 15, 2009 at 0658 LT

Type of aircraft:

Cessna 208B Grand Caravan

Operator:

Registration:

ZS-OTU

Flight Phase:

Takeoff (climb)

Flight Type:

Cargo

Survivors:

Site: