Crash of a Boeing 737-8F2 in Amsterdam: 9 killed

Date & Time: Feb 25, 2009 at 1026 LT
Type of aircraft:
Operator:
Registration:
TC-JGE
Survivors:
Yes
Schedule:
Istanbul - Amsterdam
MSN:
29789/1065
YOM:
2002
Flight number:
TK1951
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
128
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
17000
Captain / Total hours on type:
10885.00
Copilot / Total flying hours:
4146
Copilot / Total hours on type:
44
Circumstances:
Turkish Airlines Flight 1951, a Boeing 737-800, departed Istanbul-Atatürk International Airport (IST) for a flight to Amsterdam-Schiphol International Airport (AMS), The Netherlands. The flight crew consisted of three pilots: a line training captain who occupied the left seat, a first officer under line training in the right seat and an additional first officer who occupied the flight deck jump seat. The first officer under line training was the pilot flying. The en route part of the flight was uneventful. The flight was descending for Schiphol and passed overhead Flevoland at about 8500 ft. At that time the aural landing gear warning sounded. The aircraft continued and was then directed by Air Traffic Control towards runway 18R for an ILS approach and landing. The standard procedure for runway 18R prescribes that the aircraft is lined up at least 8 NM from the runway threshold at an altitude of 2000 feet. The glidepath is then approached and intercepted from below. Lining up at a distance between 5 and 8 NM is allowed when permitted by ATC. Flight 1951 was vectored for a line up at approximately 6 NM at an altitude of 2000 feet. The glide slope was now approached from above. The crew performed the approach with one of the two autopilot and autothrottle engaged. The landing gear was selected down and flaps 15 were set. While descending through 1950 feet, the radio altimeter value suddenly changed to -8 feet. And again the aural landing gear warning sounded. This could be seen on the captain’s (left-hand) primary flight display. The first officer’s (right-hand) primary flight display, by contrast, indicated the correct height, as provided by the right-hand system. The left hand radio altimeter system, however, categorised the erroneous altitude reading as a correct one, and did not record any error. In turn, this meant that it was the erroneous altitude reading that was used by various aircraft systems, including the autothrottle. The crew were unaware of this, and could not have known about it. The manuals for use during the flight did not contain any procedures for errors in the radio altimeter system. In addition, the training that the pilots had undergone did not include any detailed system information that would have allowed them to understand the significance of the problem. When the aircraft started to follow the glidepath because of the incorrect altitude reading, the autothrottle moved into the ‘retard flare’ mode. This mode is normally only activated in the final phase of the landing, below 27 feet. This was possible because the other preconditions had also been met, including flaps at (minimum) position 15. The thrust from both engines was accordingly reduced to a minimum value (approach idle). This mode was shown on the primary flight displays as ‘RETARD’. However, the right-hand autopilot, which was activated, was receiving the correct altitude from the right-hand radio altimeter system. Thus the autopilot attempted to keep the aircraft flying on the glide path for as long as possible. This meant that the aircraft’s nose continued to rise, creating an increasing angle of attack of the wings. This was necessary in order to maintain the same lift as the airspeed reduced. In the first instance, the pilots’ only indication that the autothrottle would no longer maintain the pre-selected speed of 144 knots was the RETARD display. When the speed fell below this value at a height of 750 feet, they would have been able to see this on the airspeed indicator on the primary flight displays. When subsequently, the airspeed reached 126 knots, the frame of the airspeed indicator also changed colour and started to flash. The artificial horizon also showed that the nose attitude of the aircraft was becoming far too high. The cockpit crew did not respond to these indications and warnings. The reduction in speed and excessively high pitch attitude of the aircraft were not recognised until the approach to stall warning (stick shaker) went off at an altitude of 460 feet. The first officer responded immediately to the stick shaker by pushing the control column forward and also pushing the throttle levers forward. The captain however, also responded to the stick shaker commencing by taking over control. Assumingly the result of this was that the first officer’s selection of thrust was interrupted. The result of this was that the autothrottle, which was not yet switched off, immediately pulled the throttle levers back again to the position where the engines were not providing any significant thrust. Once the captain had taken over control, the autothrottle was disconnected, but no thrust was selected at that point. Nine seconds after the commencement of the first approach to stall warning, the throttle levers were pushed fully forward, but at that point the aircraft had already stalled and the height remaining, of about 350 feet, was insufficient for a recovery. According to the last recorded data of the digital flight data recorder the aircraft was in a 22° ANU and 10° Left Wing Down (LWD) position at the moment of impact. The airplane impacted farmland. The horizontal stabilizer and both main landing gear legs were separated from the aircraft and located near the initial impact point. The left and right engines had detached from the aircraft. The aft fuselage, with vertical stabilizer, was broken circumferentially forward of the aft passenger doors and had sustained significant damage. The fuselage had ruptured at the right side forward of the wings. The forward fuselage section, which contained the cockpit and seat rows 1 to 7, had been significantly disrupted. The rear fuselage section was broken circumferentially around row 28.
Probable cause:
During the accident flight, while executing the approach by means of the instrument landing system with the right autopilot engaged, the left radio altimeter system showed an incorrect height of -8 feet on the left primary flight display. This incorrect value of -8 feet resulted in activation of the ‘retard flare’ mode of the auto-throttle, whereby the thrust of both engines was reduced to a minimal value (approach idle) in preparation for the last phase of the landing. Due to the approach heading and altitude provided to the crew by air traffic control, the localiser signal was intercepted at 5.5 NM from the runway threshold with the result that the glide slope had to be intercepted from above. This obscured the fact that the auto-throttle had entered the retard flare mode. In addition, it increased the crew’s workload. When the aircraft passed 1000 feet height, the approach was not stabilized so the crew should have initiated a go around. The right autopilot (using data from the right radio altimeter) followed the glide slope signal. As the airspeed continued to drop, the aircraft’s pitch attitude kept increasing. The crew failed to recognize the airspeed decay and the pitch increase until the moment the stick shaker was activated. Subsequently the approach to stall recovery procedure was not executed properly, causing the aircraft to stall and crash.
Final Report:

Crash of a Lockheed C-130H Hercules in Egypt

Date & Time: Feb 24, 2009
Type of aircraft:
Operator:
Registration:
1272
Flight Type:
Survivors:
Yes
MSN:
4714
YOM:
1977
Location:
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a night training mission with touch-and-go on an airbase somewhere in Egypt. In unknown circumstances, the aircraft crashed on landing and was damaged beyond repair. There were no casualties. The aircraft had the dual registration SU-BAC (civil) and 1272 (military).

Crash of a PZL-Mielec AN-2SX in Bishkek

Date & Time: Feb 22, 2009 at 1249 LT
Type of aircraft:
Operator:
Registration:
EX-68039
Flight Phase:
Survivors:
Yes
Schedule:
Bishkek - Bukhara
MSN:
1G193-11
YOM:
1981
Flight number:
GRA4571
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8215
Captain / Total hours on type:
7362.00
Copilot / Total flying hours:
7613
Copilot / Total hours on type:
4985
Aircraft flight hours:
6132
Circumstances:
The single engine aircraft departed from a small airstrip in Bishkek on a charter service (flight GRA4571) to Bukhara with two passengers and two pilots on board. About a minute after takeoff, while in initial climb, the engine lost power. The crew informed ATC about the situation and was cleared for an immediate return. Shortly later, the engine failed and the crew attempted an emergency landing in an open field located near the aerodrome. Upon landing, the aircraft collided with a small drainage ditch, lost its left main gear and both left wings before coming to rest. All four occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The reason for the loss of engine power in flight, most likely, was a reduction in the filing of the gasoline due to clogging of fuel filters. The appearance, structure and nature of the impurities found in the fuel on the aircraft were not characteristic of impurities accumulated in the fuel supply system in normal operating conditions. The source of the impurities in aircraft fuel system could not be found.
Final Report:

Crash of an Antonov AN-12B in Luxor: 5 killed

Date & Time: Feb 20, 2009 at 0418 LT
Type of aircraft:
Operator:
Registration:
S9-SVN
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kisangani – Entebbe – Luxor – Mykolaiv
MSN:
6 3 443 10
YOM:
1966
Flight number:
LFT1015
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
20000
Copilot / Total flying hours:
6397
Aircraft flight hours:
11692
Aircraft flight cycles:
6451
Circumstances:
The four engine aircraft was transferred from Kisangani to Mykolaiv, Ukraine, for maintenance purposes. Two enroute stops were scheduled in Entebbe and Luxor. Ar 0417LT, the crew was cleared for takeoff. The aircraft started rolling on runway 02 for takeoff but it kept rolling on it till it reached its end. The aircraft continued rolling in the sand drifting from the runway centerline to the right, crossing a service road and eventually crashing into a military zone located 500 metres from the runway end. The aircraft crashed into one of the buildings inside the military unit causing complete destruction of the building. The right wing also crashed into another building putting the aircraft on fire and forcing the aircraft to turn right. The aircraft kept moving forward the military unit fence (next to Tiba-Luxor road) and stopped there, crashing in its way into oil barrel. The accident resulted in the total destruction and fire of the aircraft and the fatality of its crew but no further injuries.
Probable cause:
The following factors were identified:
- Lack of available thrust which corresponded to the power of only two engines running during take off run,
- Lack of authorized maintenance of the aircraft,
- The uncoordinated crew actions in the critical situation (both pilots had previously flown as captains). The lack of coordination is confirmed by the braking trails left by the main landing gear at the end of RWY -02, based on FCOM instructions, and in case of rejected takeoff attempt, the crew had to set the throttles to idle, lower the nose gear to reach the runway and then use the propellers for braking (releasing them from the stops). Also, to reduce the roll and to maintain the direction they were to use the nose wheel steering and wheel brakes as well as emergency braking if needed. Actually the crew did neither of the above procedures, except using the main wheel brakes.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Nome

Date & Time: Feb 19, 2009 at 1812 LT
Operator:
Registration:
N41185
Survivors:
Yes
Schedule:
Brevig Mission – Nome
MSN:
31-8553001
YOM:
1985
Flight number:
FTA8218
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24850
Captain / Total hours on type:
7500.00
Aircraft flight hours:
10928
Circumstances:
The scheduled commuter flight was about 10 miles north of the destination airport, operating under a special visual-flight-rules clearance, and descending for landing in instrument meteorological conditions. According to the pilot he started a gradual descent over an area of featureless, snow-covered, down-sloping terrain in whiteout and flat light conditions. During the descent a localized snow shower momentarily reduced the pilot’s forward visibility and he was unable to discern any terrain features. The airplane collided with terrain in an all-white snow/ice field and sustained substantial damage. At the time of the accident the destination airport was reporting visibility of 1.5 statute miles in light snow and mist, broken layers at 900 and 1,600 feet, and 3,200 feet overcast, with a temperature and dew point of 25 degrees Fahrenheit. The pilot reported that there were no pre accident mechanical problems with the airplane and that the accident could have been avoided if the flight had been operated under an instrument-flight-rules flight plan.
Probable cause:
The pilot's continued flight into adverse weather and his failure to maintain clearance from terrain while on approach in flat light conditions.
Final Report:

Ground explosion of a Basler BT-67 in Medellín

Date & Time: Feb 18, 2009 at 1510 LT
Type of aircraft:
Operator:
Registration:
PNC-0211
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Medellín – Quibdó
MSN:
25667
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Parked on the apron at Medellín-Enrique Olaya Herrera Airport, the aircraft was prepared for a flight to Quibdó with two pilots and 25 policemen from the Escuadrón Móvil Antidisturbios (ESMAD). While the people were boarding the airplane, an explosion occurred. The aircraft was destroyed but there was no serious injuries among the 27 people. It is believed that the explosion was caused by the inadvertent detonation of a grenade used by one of the policemen.

Crash of a Basler BT-67 in Palanquero: 5 killed

Date & Time: Feb 18, 2009 at 0800 LT
Type of aircraft:
Operator:
Registration:
FAC-1670
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Palanquero - Palanquero
MSN:
19125
YOM:
1943
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
One instructor and four student pilots were engaged in a training mission from Palanquero-German Olano Airport. In unknown circumstances, the converted turboprop DC-3 crashed 8 km from the airport. All five occupants were killed and the aircraft was destroyed.

Crash of a HESA IrAn-140-100 in Isfahan: 5 killed

Date & Time: Feb 16, 2009
Type of aircraft:
Operator:
Registration:
90-04
Flight Type:
Survivors:
No
Schedule:
Isfahan - Isfahan
MSN:
90-04
YOM:
2007
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew was performing a training flight on behalf of the Iranian constructor HESA (Iran Aircraft Manufacturing Industrial Company) which built the Antonov AN-140 under licence with the name HESA IrAn-140-100. On final approach to Isfahan-Shahin Shahr-HESA Airport, the aircraft crashed in unknown circumstances and was destroyed. All five occupants, one instructor and four pilots under training, were killed.

Crash of an Avro RJ100 in London-City

Date & Time: Feb 13, 2009 at 2040 LT
Type of aircraft:
Operator:
Registration:
G-BXAR
Survivors:
Yes
Schedule:
Amsterdam - London-City
MSN:
E3298
YOM:
1997
Flight number:
BA8456
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4730
Captain / Total hours on type:
2402.00
Circumstances:
Following a normal touchdown, the fracture of the nose landing gear main fitting allowed the nose gear to collapse rearwards and penetrate the lower fuselage, causing significant damage to the equipment bay and the battery to become disconnected. The penetration of the fuselage allowed smoke and fumes produced by the consequent release of hydraulic fluid to enter the cockpit and passenger cabin. With the battery disconnected and after the engines were shut down, all power to the aircraft PA systems was lost and the remote cockpit door release mechanism became inoperative. No pre-accident defects were identified with the manual cockpit door release mechanism or the PA system.
Probable cause:
The nose landing gear main fitting failed following the formation of multiple fatigue cracks within the upper section of the inner bore, originating at the base of machining grooves in the bore surface. These had formed because the improved surface finish, introduced by SB 146-32-150, had not been properly embodied at previous overhaul by Messier Services Inc, despite their overhaul records showing its incorporation. The operator had been in full compliance with the Service Bulletin relating to regular inspection of the main fitting, and embodiment of SB 146-32-150 at overhaul removed the requirement for these inspections by the operator.
Final Report:

Crash of a BAe 3201 Jetstream 31 in Heraklion

Date & Time: Feb 12, 2009 at 1723 LT
Type of aircraft:
Operator:
Registration:
SX-SKY
Survivors:
Yes
Schedule:
Rhodes – Heraklion
MSN:
829
YOM:
1988
Flight number:
SEH103
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24000
Captain / Total hours on type:
570.00
Copilot / Total flying hours:
1800
Copilot / Total hours on type:
250
Aircraft flight hours:
13222
Aircraft flight cycles:
15349
Circumstances:
Flight SEH102/103 of 12 February 2009 was a scheduled passenger carrying flight performing the route Heraklion – Rhodes – Heraklion. The crew that was going to perform the flight reported for duty at 16:00 h. The aircraft had earlier on the same day performed, with a different flight crew, four routes (Heraklion – Rhodes – Heraklion and Heraklion – Samos – Heraklion), without any problems being reported. Nothing had been observed during the pre-flight check. The aircraft departed Heraklion at 16:55 h and landed at Rhodes at 17:35 h without incident. At 18:30 h the aircraft departed Rhodes for Heraklion, carrying three crew members and 15 passengers. The pilot flying (PF) this particular sector was the Pilot in Command (PIC). At a distance of 30 nm from Heraklion and at a altitude of 7700 ft on its descent to 3000 ft, the crew informed the Air Traffic Control that it had the runway in sight and requested and was granted clearance to perform a visual approach. The aircraft, fully configured for landing from a distance of 7nm, approached the airport for landing at runway 27. The wind information provided by the Air Traffic Control was 18 kt – 25 kt, from 210°. While approaching the runway, the PF asked the First Officer (FO) to check the angle of descent based on the APAPIs’ of the runway. The FO confirmed the correct angle of descent, saying “one white, one red”. The aircraft crossed the threshold with a speed of 112 kt and after flaring the PF reduced speed to Flight Idle and touched down with a speed of 86 kt. As the speed was being gradually reduced, the PF had difficulty with controlling the aircraft along its longitudinal axis and noticing that the aircraft was leaning somewhat to the right, reported to the FO that “the gear has broken”. Immediately afterwards, the blades of the right propeller of the aircraft struck the runway. As the aircraft continued to move with the left main landing gear wheel operating normally and the collapsed right main landing gear, folded backwards under the wing, being dragged along the runway, the crew stopped the engines, reported to the Airport Control Tower that the right landing gear had broken and requested evacuation. The aircraft stopped in the runway with its nose wheel at 4.6 m to the right of the center line, at a distance of 930 m from the point of the propeller’s first contact with the runway. Immediately afterwards the PF ordered the cabin crew to open the cabin door and evacuated the aircraft, and the FO, who observed some fuel leaking from the right engine, switched off the electrical systems and requested through the Airport Control Tower that the fire trucks, which were on their way, to throw foam on the right wing to prevent any fire being started. The passengers disembarked from the left aft door without any problems with the assistance of the cabin crew, while the fire trucks covered the right wing with foam as a preventive measure. The airport, applying the standing procedures, removed the aircraft and released the runway for operation at 22:30 h. During the period of time that runway 09/27 remained out of operation, two flights approaching the airport for landing were diverted to Chania Airport, and the departures of another three flights were delayed.
Probable cause:
CONCLUSIONS
Findings:
- The flight crew met all the requirements for the performance of the flight.
- The aircraft was airworthy.
- The aircraft’s landing gears have a life of 50,000 cycles (landings) and the interval between two overhauls is six years or 10,000 cycles, whichever comes sooner.
- The fractured landing gear had completed 23,940 cycles since new and had been subjected to an overhaul on 17.09.08. Since then and as of the date of the accident it had completed 148 cycles.
- The aircraft manufacturer had issued an SB, and the UK Civil Aviation Authority an AD, asking for tests and inspection applicable to Region “A” of the main landing gear cylinders.
- Said AD had been carried out without findings in the course of the landing gear overhaul of 17.09.08 by an EASA-Part 145 approved maintenance organization.
- On 02.01.09 a visual inspection of Region “A” of the main landing gear cylinders was carried out by the aircraft operator’s maintenance organization, in accordance with Part B of the SB, again without findings.
- On 07.02.09 and in the morning of 12.02.09 the aircraft made ‘heavy’ landings considering that vertical acceleration values of 2.8 g and 2.5 g, respectively, had been recorded. None of these landings had been recorded in the aircraft’s log in order to trigger the inspection prescribed in the aircraft’s maintenance manual after a ‘heavy’ landing.
- According to the technical examination of the fractured parts, the first crack developed in Region “A” (fracture surface “A2-B2”) increasing the loading upon the cylinder material surrounding the threaded fasteners, sites of stress concentration. The second and third cracks then initiated at the site of stress concentration and propagated within the cylinder to form fracture surfaces “A1” - “B1” in the region surrounding the threaded fasteners. The cracks and the fracture resulted from the ductile overload of the undercarriage cylinder which is likely to have resulted from a ‘heavy’ landing made by the aircraft.
Probable Causes:
Landing gear cylinder failure because of ductile overload resulting from a ‘heavy’ landing made by the aircraft.
Final Report: