Crash of a Boeing 737-282 in Port Harcourt

Date & Time: Jul 14, 2008 at 1844 LT
Type of aircraft:
Operator:
Registration:
5N-BIG
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
23044/973
YOM:
1983
Flight number:
NCH138
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8688
Captain / Total hours on type:
452.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
2500
Aircraft flight hours:
55508
Aircraft flight cycles:
36263
Circumstances:
On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO). Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and The First Officer (FO) was the Pilot Monitoring (PM). The FO stated that NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed due to loading of passenger baggage. The Captain stated that NCH138 was cleared to FL290 and the flight continued normally. According to the DNPO Air Traffic Control (ATC) watch supervisor on duty, NCH138 contacted DNPO Approach Control (APP) at 17:05 h with flight information estimating POT at 17:50 h. NCH138 was issued an inbound clearance to POT1 VOR2 with the following weather information for 17:00 h as: Wind calm, Visibility 10 km, Broken clouds 270 m, Scattered clouds 600 m, Cumulonimbus clouds scattered, temperature 25/24°C, Thunderstorms, Temporarily Variable 8 kt, gusting 18 kt, Visibility 3000 m, Thunderstorms and rain, and expect runway (RWY) 21 for landing. According to the First Officer NCH138 requested descent into POT at about 100 NM. The Captain added that due to ATC delay, the descent commenced at about 80 NM. The Control Tower Watch Supervisor stated that at 18:00 h, NCH138 requested to hold over POT at 3500 ft for weather improvement, because there was rain overhead the station with build-up closing in at the threshold of RWY 21. At about 15 NM, between radials 180° and 210°, NCH138 reported breaking out of weather. At 18:19 h, NCH138 requested weather information from the Tower. Tower advised the flight crew that RWY 03 was better for landing. At this time, NCH138 requested RWY 03 for approach and Approach Control cleared NCH138 for the approach to RWY 03. At 18:27 h, the flight crew reported established on approach to RWY 03, leaving 2000 ft. The Approach Control then transferred NCH138 to DNPO Tower for landing instructions. At 18:28 h, the Tower instructed NCH138 to report field in sight. The flight crew acknowledged and reported RWY 03 in sight. Tower cleared NCH138 to land on RWY 03 and NCH138 was cautioned that the runway was wet. At 18:34 h, NCH138 executed and reported a missed approach. NCH138 requested a climb to 3500 ft. NCH138 was cleared to climb and instructed to report overhead POT. At 18:39 h, NCH138 requested a descent and clearance for an approach to RWY 21. Approach Control cleared NCH138 to descend to 2000 ft and report to Tower when established on the approach and also to report leaving 2000 ft. At 18:42 h, NCH138 reported inbound maintaining 2000 ft. The Approach Control requested the distance from the runway and sought consent of NCH138 for Arik 514 at the holding point to take off. NCH138 declined, as they were about 10 miles to touchdown. At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and thereafter handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100 /10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance. NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway. The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately. All occupants on board were evacuated; one passenger sustaining a minor injury.
Probable cause:
The decision to land following an unstabilized approach (high rate of descent and high approach speed. A go-around was not initiated.
Contributory factors:
1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
2. The runway was wet with significant patches of standing water.
Final Report:

Crash of a Beechcraft 99A Airliner in Puerto Montt: 9 killed

Date & Time: Jul 10, 2008 at 1025 LT
Type of aircraft:
Operator:
Registration:
CC-CFM
Flight Phase:
Survivors:
No
Schedule:
Puerto Montt - Melinka
MSN:
U-145
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
17145
Captain / Total hours on type:
563.00
Circumstances:
Shortly after take off, while in initial climb, the pilot declared an emergency after the left engine cowling accidentally opened. He decided to return for an emergency landing and completed a turn. While on final, the pilot elected to maintain 200 feet but the aircraft stalled and crashed 1,500 metres short of runway 01. The aircraft was totally destroyed and all nine occupants were killed.
Probable cause:
Operational error of the pilot in command by not applying normal approach procedures recommended by the manufacturer and loss control of the aircraft (stall) while returning to land with the left engine cowling open.
The following contributing factors were identified:
- During the preflight inspection, the pilot failed to detect that the left engine cowling was unlatched,
- Return with the intention of landing with a speed very close to the stall speed, possibly to avoid the detachment of the engine cowling due to the wind force,
- Probable increased stall speed by altering the left wing aerodynamics due to the engine open cowl,
- Not having high enough altitude to recover from a stall condition,
- Possible decreased physiological capabilities of the commander of the aircraft, due to the presence of alcohol in his system,
- Possible pilot distraction due to weather conditions and the opening of the engine cowling.
Final Report:

Crash of a Let L-410UVP-E9 in Kichwa Tembo

Date & Time: Jul 10, 2008 at 0820 LT
Type of aircraft:
Operator:
Registration:
5Y-VVB
Flight Phase:
Survivors:
Yes
MSN:
96 27 04
YOM:
1996
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the copilot noticed abnormal parameters on the right engine and a possible failure. The captain confirmed and rejected the take off procedure. The twin engine aircraft was unable to stop within the remaining runway 08, overran, collided with a termite mound and came to rest 140 metres further on. All 13 occupants escaped uninjured while the aircraft was damaged beyond economical repair.

Crash of a Boeing 747-209BSF in Bogotá: 2 killed

Date & Time: Jul 7, 2008 at 0352 LT
Type of aircraft:
Operator:
Registration:
N714CK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bogotá – Miami
MSN:
22446/519
YOM:
1981
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8874
Captain / Total hours on type:
2874.00
Copilot / Total flying hours:
11373
Copilot / Total hours on type:
2853
Aircraft flight hours:
90613
Circumstances:
Shortly after take off from Bogotá-El Dorado Airport, while climbing by night, the crew informed ATC about engine problems and was cleared for an immediate return. After the crew realized he could not make it, he attempted an emergency landing when the aircraft collided with a farm and crashed in an open field. While all 8 crew members were injured (five seriously), two people in the farm were killed. The aircraft was totally destroyed by impact forces.
Probable cause:
The inability of the accident aircraft to maintain flight after the loss of power of two engines.
The following contributing factors were identified:
A non-recoverable surge on the engine n°4 during the rotation, resulting in a loss of engine power. Contributing to the surge were the combined effects of the inefficient high pressure turbine, excessive blade-tip clearance, reduced cord of the fan blades and of the leading edges and the effects of high altitude. An undetermined anomaly in the engine n°1, which manifested itself during the extra power, resulted in loss of engine power. Contributing to the loss of engine power was inadequate n°1 operation to maintain the proper speed during the ascent of the aircraft, resulting in extra power use and, in turn, exposing the anomaly of the engine.
Final Report:

Crash of a Douglas DC-9-15F in Saltillo: 1 killed

Date & Time: Jul 6, 2008 at 0113 LT
Type of aircraft:
Operator:
Registration:
N199US
Flight Type:
Survivors:
Yes
Schedule:
Hamilton – Shreveport – Saltillo
MSN:
47153/185
YOM:
1967
Flight number:
JUS199
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7146
Captain / Total hours on type:
2587.00
Copilot / Total flying hours:
6842
Copilot / Total hours on type:
88
Aircraft flight hours:
54141
Aircraft flight cycles:
69161
Circumstances:
The aircraft departed Hamilton, Ontario, on a cargo flight to Saltillo, Coahuila, with an intermediate stop in Shreveport, LA, carrying two pilots and a load consisting of 4 tons of auto parts. The aircraft arrived in Shreveport at 2319LT and departed at 2348LT. On approach to Saltillo-Plan de Guadalupe Airport, the crew encountered low visibility due to poor weather conditions and dark night. On final approach to runway 17, as the captain was unable to establish a visual contact with the runway, he decided to abandon the approach and initiated a go-around procedure. Nine seconds later, the aircraft stuck the ground and crashed 550 metres to the east of the runway 17 threshold, bursting into flames. The aircraft was totally destroyed, the captain was killed and the copilot was seriously injured.
Probable cause:
The continuation of an unstable final approach without having the runway in sight and the consequent loss of control at low altitude in view of the imminent impact.
The following contributing factors were identified:
- Weather conditions at the airport,
- Unstabilized approach,
- Crew fatigue,
- Lack of experience of the copilot,
- Failure to follow proper procedures,
- Lack of operational procedures,
- Not following proper Saltillo tower controller procedures,
- Lack of supervision by the authority,
- The coincidence of factors that individually would not represent a substantial increase in the risk of the operations, but that in this case were added, that is; late night flight, little experience of the co-pilot, omission of briefing by the captain, a single Jeppesen for two pilots, DME #2 inoperative, captain command bars inoperative, DME arc, ILS/DME approach, omission of fog bank report and finally saturation in the communications with the Monterrey Control Center.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Charallave: 3 killed

Date & Time: Jul 2, 2008 at 2321 LT
Type of aircraft:
Registration:
YV-1165
Flight Type:
Survivors:
No
Schedule:
San Cristóbal – Charallave
MSN:
31-7820067
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed San Cristóbal-Paramillo Airport on a private flight to Charallave with two passengers and one pilot on board. At 2319LT, he was cleared for a VOR-DME approach to runway 10. It was dark but the visibility was about 10 km. Shortly later, another aircraft on approach declared an emergency and became priority. The pilot was instructed to follow a holding pattern when two minutes later, the aircraft struck trees and crashed in a wooded and hilly terrain, bursting into flames. The wreckage was found the following morning 5,5 km northeast of the airport. The aircraft was totally destroyed and all three occupants were killed.
Probable cause:
Given the circumstances in which the accident occurred, it would be considered a CFIT (Controlled Flight Into Terrain) type accident, which occurs as a result of unintentional impact on the ground, when the aircraft is under the control of the pilot in command. It is considered that the most probable cause of the accident was the loss of situational awareness, caused mainly by the concern that he was becoming distracted by the emergency of the aircraft preceding him on the approach, because of his administrative relationship with this aircraft and its crew.
Final Report:

Explosion of a Tupolev TU-154M in Saint Petersburg

Date & Time: Jun 30, 2008 at 1548 LT
Type of aircraft:
Operator:
Registration:
RA-85667
Flight Phase:
Survivors:
Yes
Schedule:
Saint Petersburg - Moscow
MSN:
89A825
YOM:
1989
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
103
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, at a speed of 32 knots, the engine n°1 (a Soloviev D-30KU-154-II) exploded. The crew abandoned the takeoff procedure and started an emergency braking manoeuvre. The aircraft was stopped on the main runway and all 112 occupants evacuated safely. The aircraft was considered as damaged beyond repair as several compressor elements punctured the engine n°1 nacelle, hit the fuselage and n°2 engine structure. A fire erupted on the left engine and destroyed the nacelle and a part of APU as well.
Probable cause:
Left engine compressor disintegration during the takeoff roll.

Crash of an Ilyushin II-76TD in Khartoum: 4 killed

Date & Time: Jun 30, 2008 at 0700 LT
Type of aircraft:
Operator:
Registration:
ST-WTB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Khartoum – Juba
MSN:
10034 99994
YOM:
1990
Flight number:
BBE700
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
15634
Captain / Total hours on type:
4794.00
Circumstances:
The aircraft was cleared for takeoff and began its departure roll with flaps retracted, according to flight data recorder. The aircraft rotated at 280 kph (151 knots) and became airborne at 288 kph (155 knots) at an angle of attack of about 8-9 degrees. Tyre marks on the runway showed, that the aircraft had gone past the end of the runway, the main tyres had impacted runway end lights and the tyre tracks continued past the paved surface of the stopway. Climbing through 15 feet the pilot flying commanded the gear up and increased the pitch angle, the angle of attack increased to more than 10 degrees while the gear doors opened for gear retraction increasing the drag of the aircraft, which began to slow, the speed reduced to 305 kph (164 knots), stall speed for the takeoff weight, and the left wing began to stall, the angle of attack increased to 17 degrees, the aircraft at a height of 5-7 meters/15-23 feet. The pilot flying tried to counteract the roll to the left by fully applying left aileron which also deployed the right wing spoilers, right rudder input was provided. The pilot flying instructed the flight engineer to NOT retract flaps indicative neither pilot was aware the flaps were up. Following that instruction the flight engineer selected the flaps down, the aircraft speed was 300 kph (162 knots) and the aircraft in an unrecoverable stall with no height left. The left hand wing struck a high voltage mast about 1200 meters past the runway end at a height of 5.4 meters (18 feet) shearing off the left wing tip, contacted the flag post at the entrance of the Green Square, the left wing contacted the stem of a tree at a height of about 40 cm (1.3 feet) separating the ailerons and causing fuel spilling from the left wing, the aircraft broke through the eastern brick wall of Green Square, collided with two more electric poles causing engine #4 to separate 1504 meters from the end of the runway and impacted ground at 30 degrees nose down, 30 degrees left bank. Debris was distributed over a length of more than 500 meters, the aircraft burst into flames. All 4 crew perished in the crash, 4 people on the ground received serious, 3 more received minor injuries.
Probable cause:
The following findings were identified:
- From the CVR recording it appeared that no checklist had been used during all phases from engine start up, taxiing and take off,
- Ababeel company does not keep any records or files regarding the crew flying experience. They joined the company about four months before the accident,
- Engine n°1 showed only 96.2% N1 and thus delivered less thrust than the other three engines,
- Engine n°4 showed a 30° higher EGT than the other engines indicating that the engine was not in a satisfactory condition requiring the temperature limiter to be switched off to enable the engine to deliver the thrust needed,
- According to the FCOM the aircraft would need 2,850 meters takeoff distance at 188 tons takeoff weight with flaps at 30° and slats at 14°. As the crew did not use the checklists, either they were used to extend the flaps and slats after the aircraft gained certain speed and their attention was being drawn by monitoring the engine which the navigator asked about or another serious defect or they forgot to extend the flaps due to fatigue caused by alcohol consumption by the flight engineer and short periods of rest for the first officer. The clean aircraft lift off after rolling for a distance of 2,380 meters for take off which was a very short distance for such weight and temperature of 27°. Retracting of landing gear immediately within lift-off increased drag before the aircraft gained positive lift,
- the aircraft never climbed above 7 meters (23 feet) above ground,
- the aircraft had an automatic configuration warning which would activate at 70 +/- 15 kph, if the flaps were not extended. This system however could be switched off, or might have been malfunctioning, it did not activate during the takeoff run.

Ground fire of a Boeing 767-281SF in San Francisco

Date & Time: Jun 28, 2008 at 2218 LT
Type of aircraft:
Operator:
Registration:
N799AX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Francisco – Wilmington
MSN:
23432/145
YOM:
1986
Flight number:
ABX1611
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport, San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the airplane was parked near a loading facility, all of the cargo to be transported on the flight had been loaded, and the doors had been shut.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the design of the supplemental oxygen system hoses and the lack of positive separation between electrical wiring and electrically conductive oxygen system components. The lack of positive separation allowed a short circuit to breach a combustible oxygen hose, release oxygen, and initiate a fire in the supernumerary compartment that rapidly spread to other areas. Contributing to this accident was the Federal Aviation Administration’s (FAA) failure to require the installation of nonconductive oxygen hoses after the safety issue concerning conductive hoses was initially identified by Boeing.
Final Report:

Crash of a PZL-Mielec AN-2 in Bol’shoye Gryzlovo: 5 killed

Date & Time: Jun 27, 2008 at 1756 LT
Type of aircraft:
Operator:
Registration:
RA-01132
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bol’shoye Gryzlovo - Bol’shoye Gryzlovo
MSN:
1G238-60
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The single engine aircraft departed Bol’shoye Gryzlovo Airport at 1753LT on a local aerial photography mission, carrying three photographer and two pilots. Three minutes after takeoff, the engine failed. The crew attempted an emergency landing when the aircraft struck power cables and crashed in a wooded area, bursting into flames. All five occupants were killed.
Probable cause:
Collision of the aircraft with power lines during a forced landing following an engine failure in flight.
The following contributing factors were identified:
- The aircraft was refueled with a poor quality fuel prior to the last flight,
- Lack of fuel quality control during its storage, transportation and refueling process.