Crash of a Convair CV-580 in Columbus: 3 killed

Date & Time: Sep 1, 2008 at 1206 LT
Type of aircraft:
Operator:
Registration:
N587X
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Columbus - Mansfield
MSN:
361
YOM:
1956
Flight number:
HMA587
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
16087
Copilot / Total flying hours:
19285
Aircraft flight hours:
71965
Circumstances:
The accident flight was the first flight following maintenance that included flight control cable rigging. The flight was also intended to provide cockpit familiarization for the first officer and the pilot observer, and as a training flight for the first officer. About one minute after takeoff, the first officer contacted the tower and stated that they needed to return to land. The airplane impacted a cornfield about one mile southwest of the approach end of the runway, and 2 minutes 40 seconds after the initiation of the takeoff roll. The cockpit voice recorder (CVR) indicated that, during the flight, neither the captain nor the first officer called for the landing gear to be raised, the flaps to be retracted, or the power levers to be reduced from full power. From the time the first officer called "rotate" until the impact, the captain repeated the word "pull" about 27 times. When the observer pilot asked, "Come back on the trim?" the captain responded, "There's nothing anymore on the trim." The inspection of the airplane revealed that the elevator trim cables were rigged improperly, which resulted in the trim cables being reversed. As a result, when the pilot applied nose-up trim, the elevator trim system actually applied nose-down trim. The flight crew was briefed on the maintenance work that had been performed on the airplane; therefore, when the captain’s nose-up trim inputs were affecting his ability to control the airplane, at a minimum, he should have stopped making additional inputs and returned the airplane to the configuration it was in before the problem worsened. An examination of the maintenance instruction cards used to conduct the last inspection revealed that the inspector's block on numerous checks were not signed off by the Required Inspection Item (RII) inspector. The RII inspector did not sign the item that stated: "Connect elevator servo trim tab cables and rig in accordance with Allison Convair [maintenance manual]...” The item had been signed off by the mechanic, but not by the RII inspector. The card also contained a NOTE, which stated in bold type, "A complete inspection of all elevator controls must be accomplished and signed off by an RII qualified inspector and a logbook entry made to this effect." The RII inspector block was not signed off.
Probable cause:
The improper (reverse) rigging of the elevator trim cables by company maintenance personnel, and their subsequent failure to discover the misrigging during required post-maintenance checks. Contributing to the accident was the captain’s inadequate post-maintenance preflight check and the flight crew’s improper response to the trim problem.
Final Report:

Crash of a Cessna 340A in Angel Fire

Date & Time: Aug 31, 2008 at 2045 LT
Type of aircraft:
Registration:
N397RA
Flight Type:
Survivors:
Yes
Schedule:
Tomball – Angel Fire
MSN:
340A-0009
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4725
Captain / Total hours on type:
625.00
Aircraft flight hours:
6507
Circumstances:
The pilot reported that he was cleared for a GPS approach and broke out of the clouds at 1,800 feet. He entered a left hand traffic pattern and his last recollection was turning base. He woke up in the crashed airplane which was on fire. The airplane was destroyed. An examination of airplane systems revealed no anomalies.
Probable cause:
Controlled flight into terrain for unknown reasons.
Final Report:

Crash of a Boeing 737-2H6 in Jambi: 1 killed

Date & Time: Aug 27, 2008 at 1634 LT
Type of aircraft:
Operator:
Registration:
PK-CJG
Survivors:
Yes
Schedule:
Jakarta - Jambi
MSN:
23320/1120
YOM:
1985
Flight number:
SJY062
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7794
Captain / Total hours on type:
6238.00
Copilot / Total flying hours:
5254
Copilot / Total hours on type:
4143
Aircraft flight hours:
49996
Aircraft flight cycles:
54687
Circumstances:
On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.
Probable cause:
Contributing Factors:
- When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1,600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.
- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.
Final Report:

Crash of a Boeing 737-219 in Bishkek: 65 killed

Date & Time: Aug 24, 2008 at 2044 LT
Type of aircraft:
Operator:
Registration:
EX-009
Survivors:
Yes
Schedule:
Bichkek - Tehran
MSN:
22088/676
YOM:
1980
Flight number:
IRC6895
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
85
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
18250
Captain / Total hours on type:
2337.00
Copilot / Total flying hours:
4531
Copilot / Total hours on type:
881
Aircraft flight hours:
60014
Aircraft flight cycles:
56196
Circumstances:
On 24 August, 2008 the Boeing 737-200 aircraft registered ЕХ-009 and operated by a crew including a PIC and a Co-pilot of Itek Air was flying a scheduled passenger flight IRC 6895 from Bishkek to Tehran. Also on board there was the cabin crew (3 persons) as well as 85 passengers including two service passengers: a maintenance engineer and a representative of the Iran Aseman Airlines. Flight IRC 6895 was executed in compliance with the leasing agreement No. 023/05 of 15 July, 2005 for the Boeing 737-200 ЕХ-009 between the Kyrgyz airline, Itek Air, and the Iran Aseman Airlines. The crew passed a medical examination in the ground medical office of Manas Airport. The crew did not have any complaints of their health. The crew received a complete preflight briefing. The weather at the departure airport Manas, the destination airport and at alternate aerodromes was favourable for the flight. Total fuel was 12000 kg, the takeoff weight was 48371 kg with the CG at 24,8% MAC, which was within the B737-200 AFM limitations. After the climb to approximately 3000 m the crew informed the ATC about a pressurization system fault and decided to return to the aerodrome of departure. While they were descending for visual approach the aircraft collided with the ground, was damaged on impact and burnt. As a result of the crash and the following ground fire 64 passengers died. The passenger who was transferred on 29 August, 2008 to the burn resuscitation department of the Moscow Sklifasovsky Research Institute died of burn disease complicated by pneumonia on 23 October, 2008, two months after he got burn injuries. Thus, his death is connected with the injuries received due to the accident.
Probable cause:
The cause of the Itek Air B737-200 ЕХ-009 accident during the air-turn back due to the cabin not pressurizing (probably caused by the jamming of the left forward door seal) was that the crew allowed the aircraft to descend at night to a lower than the minimum descent altitude for visual approach which resulted in the crash with damage to the aircraft followed by the fire and fatalities. The combination of the following factors contributed to the accident:
- Deviations from the Boeing 737-200 SOP and PF/PM task sharing principles;
- Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact;
- Loss of altitude control during the missed approach (which was performed because the PIC incorrectly evaluated the aircraft position in comparison with the required descent flight path when he decided to perform visual straight-in approach);
- Non-adherence to the prescribed procedures after the TAWS warning was triggered.
Final Report:

Crash of a De Havilland DHC-8-301 in Barranquilla

Date & Time: Aug 23, 2008 at 1715 LT
Operator:
Registration:
HK-3952
Survivors:
Yes
Schedule:
Willemstad – Barranquilla
MSN:
169
YOM:
1989
Flight number:
ARE051
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7003
Captain / Total hours on type:
6691.00
Copilot / Total hours on type:
781
Aircraft flight hours:
31260
Circumstances:
Following an uneventful flight from Willemstad-Hato Airport, the crew started the approach to Barranquilla-Ernesto Cortissoz Airport runway 23. The aircraft landed 770 metres past the runway threshold. After touchdown, the crew noticed vibrations coming from the right side of the aircraft when the right main gear collapsed. The aircraft slid for few dozen metres before coming to rest on the main runway. All 31 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Fracture of the ring of the mechanical stop of the shock absorber on the right main gear, turning the whole gear into a solid structure incapable of absorbing the landing loads, due to the non-incorporation of the Airworthiness Directive AD-2006-14 in the general repair of the main gear.
Final Report:

Crash of a Beechcraft A100 King Air in Moab: 10 killed

Date & Time: Aug 22, 2008 at 1750 LT
Type of aircraft:
Registration:
N601PC
Flight Phase:
Survivors:
No
Schedule:
Moab - Cedar City
MSN:
B-225
YOM:
1975
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1818
Captain / Total hours on type:
698.00
Aircraft flight hours:
9263
Circumstances:
The twin engine aircraft, owned by the Red Canyon Aesthetics & Medical Spa, a dermatology clinic headquartered in Cedar City, was returning to its base when shortly after take off, the pilot elected to make an emergency landing due to technical problem. The aircraft hit the ground, skidded for 300 meters and came to rest in flames in the desert, near the Arches National Park. All 10 occupants, among them some cancer specialist who had traveled to Moab early that day to provide cancer screening, cancer treatment, and other medical services to citizens in Moab, were killed.
Probable cause:
The pilot’s failure to maintain terrain clearance during takeoff for undetermined reasons.
Final Report:

Crash of a Cessna 207 Skywagon in Poesoegroenoe

Date & Time: Aug 21, 2008
Registration:
PZ-TRR
Flight Phase:
Survivors:
Yes
Schedule:
Poesoegroenoe – Paramaribo
MSN:
207-0313
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Poesoegroenoe Airstrip, while in initial climb, the single engine aircraft stalled and crashed in a wooded area. All six occupants escaped with minor injuries while the aircraft was damaged beyond repair.
Probable cause:
It is believed that the accident was the consequence of an engine failure for unknown reasons.

Crash of a McDonnell Douglas MD-82 in Madrid: 154 killed

Date & Time: Aug 20, 2008 at 1424 LT
Type of aircraft:
Operator:
Registration:
EC-HFP
Flight Phase:
Survivors:
Yes
Schedule:
Madrid - Las Palmas
MSN:
53148/2072
YOM:
1993
Flight number:
JKK5022
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
166
Pax fatalities:
Other fatalities:
Total fatalities:
154
Captain / Total flying hours:
8476
Captain / Total hours on type:
5776.00
Copilot / Total flying hours:
1276
Copilot / Total hours on type:
1054
Aircraft flight hours:
31963
Aircraft flight cycles:
28133
Circumstances:
An MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain. Of the aircraft’s occupants, 154 were killed, including all six crew members. Eighteen passengers were seriously injured. The MD-82 aircraft operated Spanair flight JK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA). The estimated departure time was 13:00. The aircraft was authorized by control for engine start-up at 13:06:15. It then taxied to runway 36L from parking stand T21, which it occupied on the apron of terminal T2 at Barajas. The flaps were extended 11°. Once at the runway threshold, the aircraft was cleared for takeoff at 13:24:57. The crew informed the control tower at 13:26:27 that they had a problem and that they had to exit the runway. At 13:33:12, they communicated that they were returning to the stand. The crew had detected an overheating Ram Air Temperature (RAT) probe. The aircraft returned to the apron, parking on remote stand R11 of the terminal T2 parking area. The crew stopped the engines and requested assistance from maintenance technicians to solve the problem. The mechanic confirmed the malfunction described in the ATLB, checked the RAT probe heating section of the Minimum Equipment List (MEL) and opened the electrical circuit breaker that connected the heating element. Once complete, it was proposed and accepted that the aircraft be dispatched. The aircraft was topped off with 1080 liters of kerosene and at 14:08:01 it was cleared for engine start-up and to taxi to runway 36L for takeoff. The crew continued with the tasks to prepare the airplane for the flight. The conversations on the cockpit voice recorder revealed certain expressions corresponding to the before engine start checklists, the normal start list, the after start checklist and the taxi checklist. During the taxi run, the aircraft was in contact with the south sector ground control first and then with the central sector. On the final taxi segment the crew concluded its checks with the takeoff imminent checklist. At 14:23:14, with the aircraft situated at the head of runway 36L, it was cleared for takeoff. Along with the clearance, the control tower informed the aircraft that the wind was from 210° at 5 knots. At 14:23:19, the crew released the brakes for takeoff. Engine power had been increased a few seconds earlier and at 14:23:28 its value was 1.4 EPR. Power continued to increase to a maximum value of 1.95 EPR during the aircraft’s ground run. The CVR recording shows the crew calling out "V1" at 14:24:06, at which time the DFDR recorded a value of 147 knots for calibrated airspeed (CAS), and "rotate" at 14:24:08, at a recorded CAS of 154 knots. The DFDR recorded the signal change from ground mode to air mode from the nose gear strut ground sensor. The stall warning stick shaker was activated at 14:24:14 and on three occasions the stall horn and synthetic voice sounded in the cockpit: "[horn] stall, [horn] stall, [horn] stall". Impact with the ground took place at 14:24:23. During the entire takeoff run until the end of the CVR recording, no noises were recorded involving the takeoff warning system (TOWS) advising of an inadequate takeoff configuration. During the entire period from engine start-up while at parking stand R11 to the end of the DFDR recording, the values for the two flap position sensors situated on the wings were 0°. The length of the takeoff run was approximately 1950 m. Once airborne, the aircraft rose to an altitude of 40 feet above the ground before it descended and impacted the ground. During its trajectory in the air, the aircraft took on a slight left roll attitude, followed by a fast 20° roll to the right, another slight roll to the left and another abrupt roll to the right of 32°. The maximum pitch angle recorded during this process was 18°. The aircraft’s tail cone was the first part to impact the ground, almost simultaneously with the right wing tip and the right engine cowlings. The marks from these impacts were found on the right side of the runway strip as seen from the direction of the takeoff, at a distance of 60 m, measured perpendicular to the runway centerline, and 3207.5 m away from the threshold, measured in the direction of the runway. The aircraft then traveled across the ground an additional 448 m until it reached the side of the runway strip, tracing out an almost linear path at a 16° angle with the runway. It lost contact with the ground after reaching an embankment/drop-off beyond the strip, with the marks resuming 150 m away, on the airport perimeter road, whose elevation is 5.50 m lower than the runway strip. The aircraft continued moving along this irregular terrain until it reached the bed of the Vega stream, by which point the main structure was already in an advanced state of disintegration. It is here that it caught on fire. The distance from the initial impact site on the ground to the farthest point where the wreckage was found was 1093 m.
Probable cause:
The crew lost control of the airplane as a consequence of entering a stall immediately after takeoff due to an improper airplane configuration involving the non-deployment of the slats/flaps following a series of mistakes and omissions, along with the absence of the improper takeoff configuration warning.
The crew did not identify the stall warnings and did not correct said situation after takeoff. They momentarily retarded the engine throttles, increased the pitch angle and did not correct the bank angle, leading to a deterioration of the stall condition.
The crew did not detect the configuration error because they did not properly use the checklists, which contain items to select and verify the position of the flaps/slats, when preparing the flight. Specifically:
- They did not carry out the action to select the flaps/slats with the associated control lever (in the "After Start" checklist);
- They did not cross check the position of the lever or the status of the flap and slat indicating lights when executing the" After Start" checklist;
- They omitted the check of the flaps and slats during the "Takeoff briefing" item on the "Taxi" checklist;
- The visual check done when executing the "Final items" on the "Takeoff imminent" checklist was not a real check of the position of the flaps and slats, as displayed on the instruments in the cockpit.
The CIAIAC has identified the following contributing factors:
- The absence of an improper takeoff configuration warning resulting from the failure of the TOWS to operate, which thus did not warn the crew that the airplane's takeoff configuration was not appropriate. The reason for the failure of the TOWS to function could not be reliably established.
- Improper crew resource management (CRM), which did not prevent the deviation from procedures in the presence of unscheduled interruptions to flight preparations.
Final Report:

Crash of a Cessna 402 in Coventry: 4 killed

Date & Time: Aug 17, 2008 at 1136 LT
Type of aircraft:
Operator:
Registration:
G-EYES
Flight Type:
Survivors:
No
Schedule:
Coventry - Coventry
MSN:
402-0008
YOM:
1979
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1627
Captain / Total hours on type:
125.00
Copilot / Total flying hours:
2281
Copilot / Total hours on type:
339
Circumstances:
Cessna 402C aircraft G-EYES was engaged in flight calibration training and was making an ILS approach to Runway 23 at Coventry Airport when it was involved in a mid-air collision with a Rand KR-2 aircraft, G-BOLZ, operating in the visual circuit. The collision occurred in Class G (uncontrolled) airspace. The four occupants of G-EYES and the single occupant of G-BOLZ received fatal injuries.
Probable cause:
The investigation identified the following primary causal factor:
The two aircraft collided because their respective pilots either did not see the other aircraft, or did not see it in time to take effective avoiding action.
The investigation identified the following contributory factors:
1. The likelihood that the crew of G-EYES would see G-BOLZ in time to carry out effective avoiding action was reduced by the small size of G-BOLZ, its position relative to G-EYES and the high rate of closure between the aircraft.
2. Insufficient or inaccurate information was provided to the pilots, which did not assist them in fulfilling their duty to take all possible measures to avoid collisions with other aircraft.
3. The Aerodrome Controller’s sequencing plan, which was based on an incomplete understanding of the nature of G-EYES’ flight, was unlikely to have been successful. By the time the risk of a collision was identified, it was too late to devise an effective method of resolving the situation.
4. There were no effective measures in place to give G-EYES priority over traffic in the visual circuit
Final Report:

Crash of a Piper PA-31-310 Navajo in Tukums: 1 killed

Date & Time: Aug 16, 2008 at 1030 LT
Type of aircraft:
Operator:
Registration:
YL-CCX
Flight Type:
Survivors:
Yes
Schedule:
Riga - Tukums
MSN:
31-647
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft departed Riga on a flight to Tukums with eight people on board to take part to an airshow. Several others aircraft were also en route to Tukums but most of the pilots returned to their departure point due to the deterioration of the weather conditions. On approach to Tukums Airport runway 32, the pilot encountered poor visibility. Unable to establish a visual contact with the runway, he initiated a go-around procedure. After several circuits, he attempted a second approach under VFR mode. Too low, the aircraft struck a hill and eventually crashed in a private garden, coming to rest broken in two. All eight occupants were injured, some seriously. Few hours later, the pilot died from his injuries.