Crash of a Beechcraft C90 King Air in Chandigarh: 2 killed

Date & Time: Oct 29, 2008 at 1125 LT
Type of aircraft:
Operator:
Registration:
VT-EHY
Flight Type:
Survivors:
No
Schedule:
Chandigarh - Ludhiana
MSN:
LJ-1008
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3152
Captain / Total hours on type:
9.00
Copilot / Total flying hours:
664
Copilot / Total hours on type:
13
Aircraft flight hours:
6530
Circumstances:
On 29.10.2008 Punjab Government King Air C90 aircraft, VT-EHY met with an accident while operating flight from Chandigarh to Ludhiana. This accident was notified to DGCA by ATC at Ludhiana and Punjab Government officials shortly after the occurrence. The accident occurred when the aircraft was in the process of making second attempt for landing at Ludhiana Airport. The accident was investigated by Inspector of Accident under Rule 71 of Aircraft Rules, 1937. As per the obligations under ICAO Annex 13, notification was sent to USA, the country of aircraft manufacture, Canada, the country of engine manufacture and ICAO. Transport Safety Board Canada appointed an accredited representative and authorized engine manufacturer M/s P&W to associate with investigation of engines. Low visibility conditions were prevailing at Ludhiana at the time of accident. Due to which the crew located the runway late. They were estimating their position based on GPS. Though they did spot the runway at some stage of the approach, they lost sight of it again and were unable to locate it subsequently. They carried out orbits on the right side (East Side) of R/w 12 in an effort to visually locate the runway and then followed non standard procedure to land. Not comfortable with the approach, the crew decided to go around. Due to low visibility and that they probably did not want to lose the sight of the airfield, carried out non-standard go around. In their anxiety not to lose the sight of the field they descended in three orbits in the vicinity of the airfield on the west side of R/w 12, perhaps to land after making the short circuit from the right. However, due to smoke in the cockpit, severe disorientation, lack of qualification & experience on type of aircraft and on sighting the communication tower, the panic gripped the crew. In their anxiety, the control was lost and aircraft impacted the ground in the steep left bank. Aircraft was destroyed in the crash due to impact and post impact fire. Both the occupant on board died due to fire and collapsing aircraft structure.
Probable cause:
The accident occurred due to loss of control while in base leg for landing at R/W 12 after executing go around on R/W 12.
Contributory Factors:
1) Low visibility reduced the margin of safety, may have caused severe disorientation, influenced their decision and played on crew for use of non standard procedures.
2) Both the crew lacked qualification/experience and familiarity with the type of aircraft and terrain.
3) Smoke in the cockpit further reduced the margin of safety and distracted the attention of the crew.
4) Obstruction in the flight path made the crew to take severe action and led to loss of control.
5) Lack of operational control and supervision by the organisation.
Final Report:

Crash of a Boeing 747-228F in Brussels

Date & Time: Oct 27, 2008 at 1600 LT
Type of aircraft:
Operator:
Registration:
OO-CBA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Brussels – Dakar – Campinas
MSN:
24158/714
YOM:
1988
Flight number:
BB3101
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11360
Captain / Total hours on type:
260.00
Copilot / Total flying hours:
3536
Copilot / Total hours on type:
570
Aircraft flight hours:
82357
Aircraft flight cycles:
15773
Circumstances:
The aircraft took off from Brussels airport at 15:00 UTC. Upon rotation, the crew heard an abnormal noise, and had difficulties to get the aircraft in the air. After adjusting the engine power, the aircraft took off. Observers on the ground saw two white clouds appearing successively under the tail of the aircraft upon rotation, followed by flames. The inspection of the runway revealed that parts separated from the aircraft, amongst which the APU access door. The aircraft dumped the excess of fuel and landed back in Brussels at 16.20 UTC. Inspection on the ground revealed that large portions of the underside skin of the tail section were missing.
Probable cause:
The accident was caused by an inadequate take-off performance calculation, due to wrong gross weight data input error in the software used for the computation of the takeoff performance parameters and the failure to comply with the operator’s SOP for checking the validity of the data.
Contributing factor(s):
- Inadequate pairing of crew members with low experience.
- Lack of distraction management.
Final Report:

Crash of a Cessna 402C in Asunción: 5 killed

Date & Time: Oct 24, 2008 at 1040 LT
Type of aircraft:
Operator:
Registration:
ZP-TVA
Flight Phase:
Flight Type:
Survivors:
No
MSN:
402C-0417
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
One minute after takeoff from Asunción-Silvio Pettirossi Airport, while climbing to a height of about 1,000 feet, the aircraft entered an uncontrolled descent and crashed in an eucalyptus plantation located 6,5 km northeast of the airport. The aircraft was destroyed by a post crash fire and all five occupants were killed, two pilots and three nurses.
Probable cause:
It is believed that the loss of control and the subsequent crash was the consequence of an engine power loss following the failure of the turbo.

Crash of a Lockheed P-3C-140-LO Orion at Bagram AFB

Date & Time: Oct 21, 2008
Type of aircraft:
Operator:
Registration:
158573
Flight Type:
Survivors:
Yes
MSN:
5582
YOM:
1972
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Bagram AFB, the crew encountered difficulties to decelerate properly. Unable to stop within the remaining distance, the aircraft overran, lost its right main gear and came to rest, bursting into flames. There were no injuries among the occupants and the aircraft was damaged beyond repair.

Crash of a Boeing 737-2H4 in Caracas

Date & Time: Oct 16, 2008 at 1530 LT
Type of aircraft:
Operator:
Registration:
YV162T
Survivors:
Yes
Schedule:
Puerto Ordaz – Caracas
MSN:
23055/970
YOM:
1983
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 28R at Caracas-Maiquetía-Simón Bolívar Airport, the aircraft deviated to the left. It eventually veered off runway to the left and went down a slope, coming to rest with its nose gear torn off. All 54 occupants evacuated safely and aircraft was damaged beyond repair.

Crash of a Beechcraft 100 King Air in Bauru: 1 killed

Date & Time: Oct 12, 2008
Type of aircraft:
Registration:
N525ZS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bauru – Sorocaba
MSN:
B-66
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Bauru Airport, the twin engine aircraft encountered difficulties to maintain a positive rate of climb. It then descended until it impacted ground about 5 km from the airport. The pilot, sole on board, was killed. He was supposed to deliver the aircraft at Sorocaba Airport.

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 18 killed

Date & Time: Oct 8, 2008 at 0731 LT
Operator:
Registration:
9N-AFE
Survivors:
Yes
Schedule:
Kathmandu – Lukla
MSN:
720
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
8185
Captain / Total hours on type:
7180.00
Copilot / Total flying hours:
556
Copilot / Total hours on type:
341
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport at 0651LT on a regular schedule service to the Lukla-Tenzing-Hillary Airport. On approach to runway 06, the crew encountered poor visibility due to foggy conditions. Despite the pilot did not establish any visual contact with the ground, he continued the approach when, on short final, the aircraft struck a rock and crashed just below the runway 06 threshold, bursting into flames. The captain was seriously injured while 18 other occupants were killed, among them 12 Germans, 2 Australians and 5 Nepalese.
Probable cause:
Controlled flight into terrain after the captain decided to continue the approach under VFR mode in IMC conditions.

Crash of a Cessna 421 Golden Eagle in Oaxaca: 2 killed

Date & Time: Oct 6, 2008
Type of aircraft:
Operator:
Registration:
XB-KWG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Oaxaca – Bahias de Huatulco
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after take off from Oaxaca Airport runway 19, while in initial climb, the pilot informed ATC about an engine fire and elected to return for an emergency. Following a turn to runway 02, the pilot was informed about the presence of a Mexicana Fokker 100 that lined up and was waiting for takeoff clearance. The Cessna pilot made a 360 turn when the aircraft stalled and crashed short of runway, bursting into flames. Both occupants were killed.

Crash of a Boeing 737-3Y0 in Kaliningrad

Date & Time: Oct 1, 2008 at 2318 LT
Type of aircraft:
Operator:
Registration:
EI-DON
Survivors:
Yes
Schedule:
Barcelona - Kaliningrad
MSN:
23812/1511
YOM:
1988
Flight number:
KNI794
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5372
Captain / Total hours on type:
1258.00
Copilot / Total flying hours:
1010
Copilot / Total hours on type:
1010
Aircraft flight hours:
48514
Aircraft flight cycles:
39949
Circumstances:
The accident aircraft Boeing 737-3Y0 EI-DON, was operated by KD Avia on a flight from Kaliningrad, Russia to Barcelona, Spain and return. Flight KD793 to Barcelona was uneventful. The return flight, KD794, departed at 16:18 with 138 passengers and six crew members on board. The copilot was Pilot Flying, the captain was Pilot Monitoring. The en route part of the flight was uneventful. As the flight was descending to Kaliningrad at night in heavy rains and with gusty crosswind. During the descent flaps were first selected at 1° and thereafter to 5°. As the flaps were transitioning to this position, a flap asymmetry warning caught the attention of the crew. At 19:00 hours the captain took over control and selected flaps to 2°, the position at which there was no asymmetry warning. The crew then contacted the controller at Kaliningrad and reported that they had flap problems. As the descent was continued, the copilot performed the necessary calculations for a landing with flaps at 2°. At 19:09 the cabin crew was warned to prepare for a high-speed landing. Using the QRH to work the flap issue, the co-pilot activated the 'flap inhibit' and 'gear inhibit' switches. This "incorrect" action effectively disconnected the ground-proximity warning system (GPWS). At 19:11 it was established that the landing speed would be Vref +30, leading to a planned landing speed of 161 knots. At 19:14 the Landing Gear Warning Horn sounded due to the combination of power and flaps setting with the fact that the landing gear had not been selected down. This warning was cancelled by the crew. When the engine power was reduced to idle, the Landing Gear Warning Horn sounded again. This time the crew did not pay attention to the warning and continued to land. The airplane performed a gear up landing, sliding for 1440 m before coming to rest on the runway. The flap asymmetry issue was caused by a faulty Flap Position Transmitter. The flaps had extended to the commanded position, but the system incorrectly detected an asymmetry issue. This issue had occurred previously on EI-DON. The sensor had been replaced prior to departure from Kaliningrad that same day.
Probable cause:
The crash was caused by aircraft landing with not extended landing gear that resulted in aircraft structure and engines damage and it was caused by combination of the following adverse factors:
- Erroneous deactivation of GPWS gear warning (voice) system that was caused by failure to perform QRH recommendations on flaps warning deactivation during their asymmetrical extension;
- Presence of QRH manual on board of Boeing-737-300 EI-DON aircraft containing in Additional Deferred Item clause of Trailing Edge Flap Asymmetry chapter recommendation to the crew which are not specialized for the board configuration;
- Violation of the "Crew operating procedure of Boeing-737-300 aircraft" and non-compliance with QRH recommendations («LANDING CHECKLIST» section) with the result that the crew did not extend landing gear and did not monitor their position;
- Stereotyping on actuation of Landing Gear Warning Horn aural warning during approach as a result of which the crew deactivated it repeatedly without monitoring of landing gear position;
- Inadequate coordination of the crew resulted in lack of monitoring of compliance with FCOM and QRH requirements at occurrence and development of abnormal situation;
Appropriate safety recommendations based on the investigation results were developed.
Following this accident, both pilots lost their licence and KD Avia's AOC was revoked by Russian authorities in September 2009. The same month, KD Avia bankrupted.
Final Report:

Crash of a Pilatus PC-12 in Santa Fe: 1 killed

Date & Time: Sep 29, 2008 at 2216 LT
Type of aircraft:
Registration:
N606SL
Flight Type:
Survivors:
No
Schedule:
New York - Lubbock - Santa Fe
MSN:
1020
YOM:
2008
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2437
Captain / Total hours on type:
86.00
Aircraft flight hours:
130
Circumstances:
The pilot was approaching his home airport under dark night conditions. He reported that he was five miles from the airport and adjusted the airport lighting several times. He made no further radio calls, though his normal practice was to report his position several times as he proceeded in the landing pattern. The airplane approached the airport from the southeast in a descent, continued past the airport, and adjusted its course slightly to the left. One witness reported observing the airplane enter a left turn, then pitch down, and descend at a steep angle. The airplane impacted terrain in a steep left bank and cart wheeled. An examination of the airframe, airplane systems, and engine revealed no pre-impact anomalies. Flight control continuity was confirmed. The pilot had flown eight hours and 30 minutes on the day of the accident, crossing two time zones, and had been awake for no less than 17 hours when the accident occurred. The accident occurred at a time of day after midnight in the pilot's departure time zone. Post-accident toxicology testing revealed doxylamine and amphetamine in the pilot's tissues. The pilot had been diagnosed with attention deficit hyperactivity disorder (ADHD) almost five years prior to the accident and had taken prescription amphetamines for the disorder since that diagnosis. The FAA does not medically certify pilots who require medication for the control of ADHD. At the time of the accident, the pilot's blood level of amphetamines may have been falling, and he may have been increasingly fatigued and distracted. The use of doxylamine (an over-the-counter antihistamine, often used as a sleep aid) could suggest that the pilot was having difficulty sleeping.
Probable cause:
The pilot's incapacitation due to fatigue resulting in an in-flight collision with terrain.
Final Report: