Crash of an Antonov AN-24T in Dire Dawa

Date & Time: May 18, 2009
Type of aircraft:
Registration:
EK-46839
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dire Dawa - Bosaso
MSN:
7910201
YOM:
1967
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Dire Dawa-Aba Tenna Dejazmach Yilma Airport in foggy conditions, control was lost. The aircraft veered off runway and came to rest. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a BAe 3212 Jetstream 32 in Útila: 1 killed

Date & Time: May 10, 2009 at 0200 LT
Type of aircraft:
Operator:
Registration:
YV1467
Flight Type:
Survivors:
Yes
MSN:
927
YOM:
1991
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While cruising in bad weather conditions, the crew apparently lost his orientation and decided to divert to Útila Airport. On approach, both engines failed due to fuel exhaustion. The aircraft stalled and crashed in a dense wooded area. A pilot was killed while both other occupants were injured. The aircraft was destroyed. A load of 1,500 kilos of cocaine was found in the cabine.
Probable cause:
Double engine failure on final approach due to fuel exhaustion. Illegal flight.

Crash of a McDonnell Douglas MD-90-30 in Riyadh

Date & Time: May 8, 2009 at 1558 LT
Type of aircraft:
Operator:
Registration:
HZ-APW
Flight Type:
Survivors:
Yes
Schedule:
Jeddah - Riyadh
MSN:
53513/2257
YOM:
1999
Flight number:
SVA9061
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Saudi Arabian Airlines MD-90 was substantially damaged during a runway excursion accident Riyadh (RUH). The seven crew members escaped unhurt. The airplane operated on a repositioning flight from Jeddah. During the flight, the captain discussed the use of manual spoilers during landing with the first officer. He further stated that; as he "had only around 400 hours in the aircraft" as a captain, he wanted to "see the effect' of landing with manual spoilers. He further explained that the flight provided an opportunity to "do it manually" (use manual spoilers) as it was a repositioning flight and, the weather and dry runway conditions were ideal. As such, he discussed the procedure with the first officer and elected to land with the auto ground spoiler system unarmed. The flight was uneventful. During the approach to Riyadh the Landing Checklist was completed, which included the arming of the auto ground spoiler system for landing. After the Landing Checklist was completed, the captain disarmed the auto ground spoiler system with the intention of applying manual ground spoilers after landing. The auto braking system was also not armed prior to landing. The final approach and touchdown to runway 15 Left at Riyadh were uneventful. The touchdown airspeed was 135 knots calibrated air speed (CAS). On touchdown, the captain manually extended the spoiler/speed brake lever, but did not latch it in the fully extended (EXT) position (fully aft and latched upwards). The captain then removed his right hand from the speed brake lever in order to deploy the thrust reversers. The first officer noted the movement of the spoiler/speed brake lever and called "Spoilers Deployed". Since the spoiler/speed brake lever was not fully pulled aft and latched upwards, the lever automatically returned to the forward retracted (RET) position. This movement of the spoiler/speed brake lever was not noticed by the captain and the first officer. In response, the ground spoilers re-stowed before being fully deployed and, a speed brake/flap configuration (SPD BRK/FLP CONFIG) Level 1 Amber Alert occurred. This alert occurred as the aircraft was not yet fully weight on wheels (WOW) and the aircraft still sensed a flight condition with speed brakes deployed and flaps extended beyond six degrees. Six seconds after touchdown on the right main landing gear, the nose gear touched down and the aircraft transferred to a ground condition (WOW on nose gear and main wheel spin up). The SPD BRK/FLP CONFIG alert extinguished when the nose gear oleo actuated ground shift on landing. After touchdown, the aircraft banked to the right and began to drift right of the runway centerline. In response, he applied left rudder, deployed the thrust reversers and applied left aileron. But this did not have any noticeable effect. The captain saw the approaching G4 taxiway exit and in an attempt to keep the aircraft from leaving the runway surface beyond the G4 taxiway exit, he decided to direct the aircraft towards the taxiway. He then applied a right rudder input which caused the aircraft to commence a rapid sweeping turn to the right towards the G4 taxiway exit. The aircraft left the runway at high speed, traversed the full width of the G4 taxiway, and exited the surface at its southern edge. The aircraft then entered a sand section and travelled the distance infield between the edge of the G4 taxiway and the adjacent section of taxiway GOLF. The left main landing gear collapsed during this time. The aircraft came to rest on taxiway GOLF. There was no post impact fire.
Probable cause:
Cause Related Findings
1. The Captain decided to land with manual ground spoilers when the auto ground spoiler system was fully operational.
2. The initiative by the Captain to conduct this improvised exercise contravened the Standard Operating Procedures (SOPs) and the Flight Operations Policy Manual (FOPM).
3. The auto ground spoiler system was disarmed prior to landing.
4. The spoiler/speed brake lever was partially applied manually after landing.
5. The spoiler/speed brake lever was released before it was fully extended and latched.
6. The spoiler/speed brake lever automatically retracted as per design.
7. The ground spoilers never fully deployed.
8. The loss of lift and aircraft deceleration were greatly reduced by the lack of ground spoiler deployment.
9. Brakes were not used in an attempt to control or slowdown the aircraft.
10. The Captain applied a large right rudder input with the intention of directing the aircraft onto the G4 taxiway exit.
11. The aircraft exited the runway at high speed and was travelling too fast to successfully negotiate the right turn onto the G4 taxiway.

Crash of a Douglas DC-10-30ER in Baltimore

Date & Time: May 6, 2009 at 1302 LT
Type of aircraft:
Operator:
Registration:
N139WA
Survivors:
Yes
Schedule:
Leipzig – Baltimore
MSN:
46583/292
YOM:
1979
Flight number:
WOA8535
Crew on board:
12
Crew fatalities:
Pax on board:
168
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6500
Captain / Total hours on type:
193.00
Copilot / Total flying hours:
6300
Copilot / Total hours on type:
373
Aircraft flight hours:
107814
Circumstances:
The flight was conducting a straight-in approach during visual meteorological conditions. The approach was backed up by an ILS and was stable at 500 feet above touchdown. The initial touchdown was firm and main landing gear rebounded, possibly bouncing slightly off the runway. Control column input and possibly momentum from the touchdown resulted in a rapid pitch down and hard nose gear impact with the runway. Wing spoilers likely did not deploy due to the main gear bounce and/or throttle position. Following the nose gear impact, the airplane pitched up as expected and the column was held in a slightly forward position. Airspeed rapidly decayed, and engine power began to increase as the airplane pitch reversed to a downward motion for a second time. One of the crew, likely the FO, called “flare flare” and the column recorded a rapid nose up input, followed by a rapid nose down input, and the nose gear again struck the runway very hard, likely causing the majority of the damage at that point. Following the second nose gear impact, column inputs stabilized at a slightly nose up command, power was set on all three engines, and the go-around was successfully executed. A slight lag in the power increase on engine number 3 may have contributed to the nose down motion leading to the second nose gear impact, although the large forward (airplane nose down) column movement appears to be a much more significant contributor. It is unclear why the engine was slower to increase. Throttle lever angle was not recorded, but the engine operated as expected for all other phases of the flight, including after the impact, therefore it is possible the pilot did not advance the number 3 throttle concurrently with the others. The captain’s flight and duty schedule complied with Federal Aviation regulations, but he experienced a demanding 10-day trip schedule prior to the incident involving multiple time zone crossings and several long duty periods, and reported difficulties sleeping prior to the accident leg. The captain was likely further affected by a digestive system upset during the accident flight. It is likely that the captain’s performance was degraded by fatigue and some degree of physical discomfort brought on by a short-term illness. The captain had recently completed upgrade training to DC-10, having previously been flying as an MD-11 first officer. The training program was fragmented over approximately ten months, and while in accordance with FAA regulations, may have adversely affected his consolidation of skills and experience.
Probable cause:
The captain’s inappropriate control inputs following a firm landing, resulting in two hard nose-gear impacts before executing a go-around. Contributing to the inappropriate control inputs was the captain’s fatigue and physical discomfort; and a possible lack of practical consolidation of skills and experience due to a protracted and fragmented training period.
Final Report:

Crash of an Antonov AN-2 at Seongnam AFB

Date & Time: May 4, 2009 at 1430 LT
Type of aircraft:
Operator:
Flight Type:
Survivors:
Yes
Schedule:
Seongnam - Seongnam
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a training flight at Seongnam AFB. On approach, the single engine aircraft stalled and crashed in a vineyard and was destroyed by a post impact fire. Both crew members escaped with minor injuries.

Crash of a PZL-Mielec AN-2T in Pokrovsk: 3 killed

Date & Time: Apr 30, 2009 at 2325 LT
Type of aircraft:
Operator:
Registration:
RF-00842
Flight Type:
Survivors:
No
Schedule:
Krasnoyarsk - Lensk - Yakutsk
MSN:
1G195-55
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a positioning flight from Krasnoyarsk to Yakutsk with an intermediate stop in Lensk. The intended destination was in fact Prokovsk located about 70 km southwest of Yakutsk but the airfield was not suitable for night movements. On approach to Yakutsk-Magan Airport, the crew continued to Prokovsk where several cars were parked along the runway with their lights ON. Due to low visibility caused by night and snow falls, the crew was unable to establish a visual contact with the ground and two approaches were missed. During a third attempt to land, the aircraft collided with pine trees and power cables and crashed in an open field, bursting into flames. All three occupants were killed.
Probable cause:
The decision of the crew to land on an airfield that was not equipped for night movements.

Crash of a Boeing 737-2K9 in Guadalajara

Date & Time: Apr 27, 2009 at 1800 LT
Type of aircraft:
Operator:
Registration:
XA-MAF
Survivors:
Yes
Schedule:
Cancún – Guadalajara
MSN:
22505/815
YOM:
1981
Flight number:
GMT585
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Guadalajara-Miguel Hidalgo y Costilla Airport, the pilots encountered technical problems with the landing gear and elected to perform a low pass in front of the tower. ATC confirmed that the landing gear were not fully deployed and locked. The captain decided to perform a wheels up landing. After touchdown on runway 28, the aircraft slid for few dozen metres before coming to rest. The left engine was destroyed by fire and the aircraft was damaged beyond repair. All 116 occupants escaped uninjured.

Ground fire of a Douglas DC-3C in San Juan

Date & Time: Apr 26, 2009 at 0428 LT
Type of aircraft:
Operator:
Registration:
N136FS
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Juan - Charlotte Amalie
MSN:
10267
YOM:
1943
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
50233
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
957
Copilot / Total hours on type:
204
Aircraft flight hours:
19952
Circumstances:
During taxi to a runway, the instrument panel and cockpit floor erupted in flames. Examination of the wreckage revealed that the majority of the wires contained inside the main junction box had very little damage except for two wires that had insulation missing. The damage appeared to be associated with the routing of the two wires. Both wires were connected to the battery relay and ran through wires in and around the exposed terminal studs. Heat damage was noted on the insulation of wires and other components that were in contact with the exposed wires. The wires ran from the battery relay to the forward section of the cockpit, where the fire started. Due to the fire damage that consumed the cockpit, the examination was unable to determine what system the wires were associated with. Further examination revealed that the fuel pressure was a direct indicating system. Fuel traveled directly to the instruments in the cockpit via rigid aluminum lines routed on the right lower side of the fuselage, where more severe fire damage was noted. Review of maintenance records did not reveal any evidence of the fuel pressure indicating system lines and hoses having ever been replaced; however, they were only required to be replaced on an as-needed basis. The electrical system, instrument lines, and hoses through the nose compartment were required to be inspected on a Phase D inspection; the airplane's last Phase D inspection was completed about 9 months prior to the accident and the airplane had accrued 313.1 hours of operation since that inspection.
Probable cause:
Worn electrical wires and a fuel pressure indicating system hose, which resulted in a ground fire during taxi.
Final Report:

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

Date & Time: Apr 17, 2009 at 1545 LT
Type of aircraft:
Operator:
Registration:
YV1181
Flight Phase:
Survivors:
Yes
Schedule:
Canaima – Ciudad Bolívar
MSN:
208B-0695
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3404
Captain / Total hours on type:
1021.00
Copilot / Total flying hours:
269
Copilot / Total hours on type:
59
Aircraft flight hours:
15753
Circumstances:
After takeoff from runway 36 at Canaima Airport, while in initial climb, the single engine aircraft encountered difficulties to gain height. It collided with power lines and crashed in bushes located 80 metres past the runway end. A young boy aged 6 was killed while all other occupants were injured, seven seriously. The aircraft was destroyed.
Probable cause:
The accident occurred as a result of the inability of the aircraft to take off, affected by the tailwind and water puddles that covered part of the runway, which did not allow speed to build up, crashing into the ground. It is considered that the most likely cause of the accident was mismanagement by the crew, in the sense of failing to make adequate planning and analysis, coupled with overconfidence and lack of identification of hazardous conditions at that time of takeoff. Based on our [JIAAC] investigations, we can infer that there were several contributing causes for the occurrence of this accident. In this order, we can state the following:
- Adverse weather and tailwind conditions associated with the phenomenon.
- Incorrect management by the crew to use only the last third of the runway with the meteorological conditions prevailing at that time.
- Failure of the aerodrome administration to identify and correct poor drainage of the runway.
- Failure of the Autoridad Aeronáutica to monitor safety.
- Rejection by the crew of the concatenated form in which the factors involved in this event developed.
After all the analysis to different causes involved in this accident, we can point to as the main Causal Factor: Human Factor, due to the mismanagement by the flight crew upon takeoff in these conditions. Physical and Material factors included everything related to the prevailing weather conditions, road conditions and lack of services at the aerodrome by the authorities; all of them are considered Contributing Factors.
Final Report:

Crash of a BAe 146-300 in Wamena: 6 killed

Date & Time: Apr 9, 2009 at 0743 LT
Type of aircraft:
Operator:
Registration:
PK-BRD
Flight Type:
Survivors:
No
Schedule:
Jayapura - Wamena
MSN:
E3189
YOM:
1990
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
8305
Captain / Total hours on type:
958.00
Copilot / Total flying hours:
12389
Copilot / Total hours on type:
191
Aircraft flight hours:
22225
Circumstances:
On the morning of 9 April 2009, a British Aerospace BAe 146-300 aircraft, registered PK-BRD, was being operated by PT. Aviastar Mandiri Airlines as a scheduled passenger and cargo flight from Sentani Airport to Wamena Airport, Papua. The crew consisted of two pilots, two flight attendants, an engineer, and a load master. The aircraft performed a go-around from the initial landing approach on runway 15 at Wamena. The flight crew positioned the aircraft on a right downwind leg for another landing approach. As the aircraft was turned towards the final approach for the second landing approach at Wamena it impacted terrain and was destroyed. All of the occupants were fatally injured. The Enhanced Ground Proximity Warning System (EGPWS) manufacturer performed simulations using data from the flight recorders, and two separate terrain data sources. The manufacturer informed the investigation that “the GPWS/EGPWS alerts recorded in the CVR were issued as designed”. However the enhanced Look-Ahead function appeared to have been inhibited following the go around. There was no evidence from the CVR that the crew had deliberately inhibited the terrain function of the EGPWS. The investigation determined that the EGPWS issued appropriate warnings to the flight crew, in the GPWS mode. The pilot in command did not take appropriate remedial action in response to repeated EGPWS warnings. The investigation concluded that flight crew’s lack of awareness of the aircraft’s proximity with terrain, together with non conformance to the operator’s published operating procedures, resulted in the aircraft’s impact with terrain. As a consequence of this accident, the operator took safety action to address deficiencies in its documentation for missed approach procedures at Wamena. As a result of this accident, the National Transportation Safety Committee (NTSC) also issued safety recommendations to the operator and to the Directorate General Civil Aviation (DGCA) to ensure that relevant documented safety procedures are implemented. During the investigation, safety issues were identified concerning modification of aircraft and DGCA approval of those modifications. While those safety issues did not contribute to the accident, they nevertheless are safety deficiencies. Accordingly, the NTSC report includes recommendations to address those identified safety issues.
Probable cause:
The crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent. The flight crew did not act on the Enhanced Ground Proximity Warning System aural warnings, and did not conform to the operator’s published operating procedures. Together, those factors resulted in the aircraft’s impact with terrain.
Final Report: