Crash of a Britten-Norman BN-2A Islander in La Ceiba

Date & Time: Aug 26, 2007
Type of aircraft:
Operator:
Flight Phase:
Survivors:
Yes
Schedule:
La Ceiba – Puerto Lempira
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at La Ceiba-Goloson Airport, a tyre burst. The pilot rejected takeoff but the aircraft was unable to stop within the remaining distance. It overran and came to rest 116 metres further. All nine passengers escaped uninjured while the pilot was seriously injured. The aircraft was damaged beyond repair.

Crash of an Antonov AN-26B-100 in Pasto

Date & Time: Aug 22, 2007 at 1510 LT
Type of aircraft:
Operator:
Registration:
HK-4389
Survivors:
Yes
Schedule:
Cali – Villagarzón
MSN:
108 03
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12243
Captain / Total hours on type:
1133.00
Copilot / Total flying hours:
822
Copilot / Total hours on type:
595
Aircraft flight hours:
17124
Circumstances:
En route from Calí to Villagarzón, the crew contacted ATC and reported technical problems with the left engine. After being cleared to divert to Pasto-Antonio Nariño Airport, the crew modified his route and started the descent. On approach, the flaps were lowered at 38° and the speed was reduced to 250 km/h. After the gears were selected down, the speed increased to 270 km/h so full flaps was selected. After touchdown on runway 02 which is 2,312 metres long, the aircraft was unable to stop within the remaining distance. It overran, went down a 15 metres high embankment and came to rest, broken in two and with its left wing torn off. All 53 occupants were rescued, among them few were injured.
Probable cause:
Taking into account that the operator failed to cooperate with the investigators by sending the necessary documentation on the the anti skid system, the braking system, as well as the propellers and did not manage the reading of the flight recorders; the available evidence establishes as POSSIBLE CAUSE the failure of one or some of the related systems above; in addition to the inadequate operation during the single-engine landing, which finally produced the departure of the aircraft at the end of the runway.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Curitiba: 2 killed

Date & Time: Aug 22, 2007 at 0035 LT
Operator:
Registration:
PT-SDB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Curitiba – Jundiaí
MSN:
110-323
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
18400
Captain / Total hours on type:
8200.00
Copilot / Total flying hours:
5600
Copilot / Total hours on type:
1600
Circumstances:
After passengers were dropped at Curitiba-Afonso Pena Airport, the crew was returning to his base in Jundiaí. Shortly after takeoff from runway 11 by night and marginal weather conditions, the airplane entered clouds at an altitude of 300 feet and continued to climb. Following a left turn, the aircraft climbed to an altitude of 700 feet then entered a right turn and an uncontrolled descent until it crashed in a field located near the Guatupê Police Academy located 3 km northeast of the airport. The accident occurred two minutes after takeoff. The aircraft was totally destroyed and both pilots were killed. At the time of the accident, the visibility was poor due to the night and a cloud base at 300 feet.
Probable cause:
Loss of control during initial climb in IMC conditions after the crew suffered a spatial disorientation. The following factors were identified:
- Weather conditions were not suitable for the completion of the flight,
- The crew failed to prepare the flight according to published procedures,
- The crew failed to follow the pre-takeoff checklist,
- The copilot did not have adequate training for this type of operation,
- The captain had emotional conditions that compromised flight operations,
- The relationship between both pilots was incompatible,
- The main attitude indicator was out of service since a week and the crew referred to the emergency attitude indicator,
- Because of poor flight preparation and non observation of the pre-takeoff checklist, the captain forgot to switch on the emergency attitude indicator prior to takeoff,
- At the time of the accident, the captain had accumulated 15 hours and 22 minutes of work without rest, which is against the law,
- The captain showed overconfidence and inflexibility which weakened his performances,
- Both pilots disagreed on operations,
- The visibility was poor due to the night and the ceiling at 300 feet above ground,
- The state of complacency of the organization was characterized by a culture adaptable to internal processes, without the adoption of formal rules for the operations division and the acceptance of operating conditions incompatible with security rules and protocols, which allowed the newly hired crew to feel free to act in disagreement with the standards and regulations in force at the time of the accident,
- Performing a sharp turn to the right in IMC conditions associated with a long working day and a lack of rest,
- The level of stress of the captain due to intense fatigue generated by a high workload and an insufficient rest period,
- Poor crew discipline,
- Poor judgment of the situation,
- Poor flight planning,
- Failures in the operator's organizational processes and lack of supervision of flight operations.
Final Report:

Ground fire of a Boeing 737-809 in Naha

Date & Time: Aug 20, 2007 at 1033 LT
Type of aircraft:
Operator:
Registration:
B-18616
Flight Phase:
Survivors:
Yes
Schedule:
Taipei - Naha
MSN:
30175/1182
YOM:
2002
Flight number:
CI120
Location:
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
157
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7941
Captain / Total hours on type:
3823.00
Copilot / Total flying hours:
890
Copilot / Total hours on type:
182
Aircraft flight hours:
13664
Circumstances:
The aircraft departed Taipei-Taoyuan Airport at 0814LT on a schedule service to Naha with 157 passengers and a crew of 8. Following an uneventful flight, the crew was cleared to land on runway 18 and vacated via taxiway E6 then A5. After being stopped at spot 41, engines were shot down when a fire broke out somewhere in an area aft of the right engine and spread to the right wing leading edge near the n°5 slat and the apron surface below the right engine. All 165 occupants evacuated safely while the aircraft was totally destroyed by fire.
Probable cause:
It is considered highly probable that this accident occurred through the following causal chain: When the Aircraft retracted the slats after landing at Naha Airport, the track can that housed the inboard main track of the No. 5 slat on the right wing was punctured, creating a hole. Fuel leaked out through the hole, reaching the outside of the wing. A fire started when the leaked fuel came into contact with high-temperature areas on the right engine after the Aircraft stopped in its assigned spot, and the Aircraft burned out after several explosions. With regard to the cause of the puncture in the track can, it is certain that the downstop assembly having detached from the aft end of the above-mentioned inboard main track fell off into the track can, and when the slat was retracted, the assembly was pressed by the track against the track can and punctured it. With regard to the cause of the detachment of the downstop assembly, it is considered highly probable that during the maintenance works for preventing the nut from loosening, which the Company carried out on the downstop assembly about one and a half months prior to the accident based on the Service Letter from the manufacturer of the Aircraft, the washer on the nut side of the assembly fell off, following which the downstop on the nut side of the assembly fell off and then the downstop assembly eventually fell off the track. It is considered highly probable that a factor contributing to the detachment of the downstop assembly was the design of the downstop assembly, which was unable to prevent the assembly from falling off if the washer is not installed. With regard to the detachment of the washer, it is considered probable that the following factors contributed to this: Despite the fact that the nut was in a location difficult to access during the maintenance works, neither the manufacturer of the Aircraft nor the Company had paid sufficient attention to this when preparing the Service Letter and Engineering Order job card, respectively. Also, neither the maintenance operator nor the job supervisor reported the difficulty of the job to the one who had ordered the job.
Final Report:

Crash of a De Havilland Dash-8-Q402 in Busan

Date & Time: Aug 12, 2007 at 0938 LT
Operator:
Registration:
HL5256
Survivors:
Yes
Schedule:
Jeju - Busan
MSN:
4141
YOM:
2006
Flight number:
JJA502
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8655
Copilot / Total flying hours:
1213
Aircraft flight hours:
1645
Aircraft flight cycles:
1876
Circumstances:
On 12 August 2007, about 05:20, the flight crew showed up and prepared for the flight of Gimpo/Jeju/Gimhae/Gimpo at the crew lounge of the Gimpo Airport. For a flight duty of the flight 103 (Gimpo to Jeju section), the flight crew departed from the Gimpo Airport at about 06:50 and arrived at the Jeju Airport at about 08:15. For the flight 502 (Jeju to Gimhae section), they departed the Jeju Airport at 08:49. While the aircraft passing through an altitude of 9,500 feet), RUD CTRL caution lights and #2 RUD HYD caution lights illuminated. Accordingly, the pilots followed and carried out the procedures) of QRH (Quick Reference Handbook). Referring to the pilots’ statements, #2 RUD HYD caution lights illuminated constantly during the flight; however, RUD CTRL caution lights illuminated intermittently. As it reached a cruising altitude of 15,000 feet, the pilots notified the condition of malfunctions and actions taken according to the QRH to a mechanic stationed at the Gimhae Airport. The pilots received a clearance from the Gimhae Approach Control for ILS RWY 36L then circling approach to RWY 18R. At the final approach course of ILS DME RWY 36L, after visually identifying the runway, the captain received a clearance for conducting a circling approach on initial contact with the Gimhae Control Tower. Referring to the pilots’ statements and the data of Flight Data Recorder (hereinafter referred to as "FDR"), from 09:33:57 until 09:34:03 (for the time of turning from the final approach course of ILS to enter a downwind for circling approach), the caution lights of Elevator Feel, RUD CTRL, Pitch Trim and other warning lights illuminated on the caution and warning lights panel. However, the pilots stated that they couldn’t recall all the caution lights illuminated at the time, and did not take any measures considering the illuminating lights as "nuisance.") The first officer who was a pilot flying continued the circling approach, and aligned his aircraft with the runway 18R on the final approach course. After aligned with runway 18R, the aircraft heading was at 178 degrees magnetic. At that time, according to the ATIS information, the wind direction/speed was 130 degrees at 13 knots gusting to 18 knots, ceiling 4,000 feet, and it was mostly cloudy. According to FDR record, at 09:38:08, about 2 feet above the runway, the rudder started to be applied to the right side. Concurrently, the pilot moved the control wheel to the right. At that time, the aircraft heading changed from 174 degrees to 175 degrees. At 09:38:09, the main landing gear of the aircraft touched down on the runway, and the aircraft heading was at 174 degrees. From the point where the main landing gear touched down, the aircraft continued to drift left into the wind. Initially the pilots applied right rudder in an attempt to maintain runway center-line. Rather then apply left wing down, the control wheel input was toward the right. According to the Cockpit Voice Recorder (hereinafter referred to as "CVR"), at 09:38:11, as the captain kicked onto the rudder pedal and said, "Why, why, Ah?" and the first officer replied, "it doesn’t respond.") At 09:38:13, the nose landing gear touched down, and the pilots started to apply brakes. At 09:38:15, all of sudden, the deceleration rate dropped. According to the tire marks, the aircraft departed the left edge of the runway at 3,500 feet from the end of runway. At 09:38:19, the groaning sound of one of the pilots, "Uh. Uh" was recorded on CVR. After 09:38:15, the heading direction of the aircraft was increasing to the left. According to CVR, at 09:38:25, there was a recorded voice of the captain, "Oh, no, Gosh,"and then at 09:38:27, with a sound of crash, the captain’s screaming sound, "Ah!" was recorded. The aircraft collided into a concrete drainage ditch, which is located 340 feet away from the centerline of the runway 18R and 4,600 feet away from the end of runway, and then it came to rest. When the aircraft stopped in the concrete drainage ditch, the pilots shut off the right engine, declared emergency to the air traffic control tower, and instructed the passengers to perform emergency evacuation.
Probable cause:
The Aviation and Railway Accident Investigation Board determines that the cause of the runway excursion of the Flight 502 was that the rudder failure was not recognized by the pilots during flight and as well as during landing roll. Contributing to this accident was that:
1) the rudder was failing to respond to the pilots' rudder pedal input and
2) After departing from the runway, no appropriate alternative measure was taken to control the aircraft direction.
Final Report:

Crash of a Learjet 35A in Marigot

Date & Time: Aug 11, 2007 at 1635 LT
Type of aircraft:
Operator:
Registration:
N500ND
Survivors:
Yes
Schedule:
Saint John's - Marigot
MSN:
35A-351
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 11, 2007, at 1635 Atlantic standard time, a Gates Learjet 35A, N500ND, registered to World Jet of Delaware Inc, and operated by World Jet II as a 14 CFR 135 on-demand on-scheduled international passenger air taxi flight, went off the end of runway 09 at Melville Hall, Dominica, on landing roll out. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane received substantial damage. The airline transport rated pilot in command (PIC), first officer (FO), and four passengers reported no injuries. The flight originated from Saint John's Antigua Island on August 11, 2007, at 1600. The PIC stated the first officer was flying the airplane and the tower cleared them to enter a left downwind. On touchdown the FO requested spoilers, and noticed poor braking. The PIC pumped the brakes with no response. The drag chute was deployed but was not effective. The PIC stated he took over the flight controls and applied maximum braking. The airplane continued to roll off the end of the runway, down an embankment, through a fence, and came to a stop on a road.

Crash of a Piper PA-46-350P Malibu Mirage in Sitka: 4 killed

Date & Time: Aug 6, 2007 at 1255 LT
Registration:
N35CX
Flight Type:
Survivors:
No
Schedule:
Victoria - Sitka
MSN:
46-36127
YOM:
1997
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
1800
Aircraft flight hours:
2042
Circumstances:
The private, instrument-rated pilot, was on an IFR cross-country flight, and had been cleared for a GPS approach. He reported that he was 5 minutes from landing, and said he was circling to the left, to land the opposite direction from the published approach. The traffic pattern for the approach runway was right traffic. Instrument meteorological conditions prevailed, and the weather conditions included a visibility of 3 statute miles in light rain and mist; few clouds at 400 feet, 1,000 feet overcast; temperature, 55 degrees F; dew point, 55 degrees F. The minimum descent altitude, either for a lateral navigation approach, or a circling approach, was 580 feet, and required a visibility of 1 mile. The missed approach procedure was a right climbing turn. A circling approach north of the runway was not approved. Witnesses reported that the weather included low clouds and reduced visibility due to fog and drizzle. The airplane was heard, but not seen, circling several times over the city, which was north of the runway. Witnesses saw the airplane descending in a wings level, 30-45 degree nose down attitude from the base of clouds, pitch up slightly, and then collide with several trees and an unoccupied house. A postcrash fire consumed the residence, and destroyed the airplane. A review of FAA radar data indicated that as the accident airplane flew toward the airport, its altitude slowly decreased and its flight track appeared to remain to the left side (north) of the runway. The airplane's lowest altitude was 800 feet as it neared the runway, and then climbed to 1,700 feet, where radar contact was lost, north of the runway. During the postaccident examination of the airplane, no mechanical malfunction was found. Given the lack of any mechanical deficiencies with the airplane, it is likely the pilot was either confused about the proper approach procedures, or elected to disregard them, and abandoned the instrument approach prematurely in his attempt to find the runway. It is unknown why he decided to do a circle to land approach, when the tailwind component was slight, and the shorter, simpler, straight in approach was a viable option. Likewise, it is unknown why he flew towards rising terrain on the north side of the runway, contrary to the published procedures. From the witness statements, it appears the pilot was "hunting" for the airport, and intentionally dove the airplane towards what he perceived was an area close to it. In the process, he probably saw
trees and terrain, attempted to climb, but was too low to avoid the trees.
Probable cause:
The pilot's failure to maintain altitude/distance from obstacles during an IFR circling approach, and his failure to follow the instrument approach procedure. Contributing to the accident was clouds.
Final Report:

Crash of a Beechcraft B200 Super King Air in Garissa

Date & Time: Aug 6, 2007
Operator:
Registration:
5Y-HHM
Flight Type:
Survivors:
Yes
Schedule:
Nairobi - Garissa
MSN:
BB-1152
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight from Nairobi to Garissa. On final approach to Garissa, a donkey entered the runway. The crew initiated a go-around procedure but the aircraft stalled and landed very hard. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Beechcraft E90 King Air in Ruidoso: 5 killed

Date & Time: Aug 5, 2007 at 2141 LT
Type of aircraft:
Operator:
Registration:
N369CD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ruidoso - Albuquerque
MSN:
LW-162
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2775
Captain / Total hours on type:
23.00
Aircraft flight hours:
10358
Circumstances:
The emergency medical services (EMS) airplane took off toward the east in dark night visual conditions. The purpose of the Part 135 commercial air ambulance flight was to transport a 15-month-old patient from one hospital to another. Immediately following the takeoff from an airport elevation of 6,814 feet above mean sea level (msl), witnesses observed the airplane initiate a left turn to the north and disappear. Satellite tracking detected the airplane a shortly after departure, when the airplane was flying at an altitude of 6,811 feet msl, an airspeed of 115 knots, and a course of 072 degrees. The airplane impacted terrain at an elevation of 6,860 msl feet shortly thereafter, about 4 miles southeast of the departure airport. The pilot, flight nurse, paramedic, patient, and patient's mother were fatally injured. When the airplane failed to arrive at its destination, authorities initiated a search and the wreckage was located the next morning. Documentation and analysis of the accident site by the NTSB revealed that debris path indicated a heading away from the destination airport. Initial impact with trees occurred at an elevation of 6,860 feet. Fragmented wreckage was strewn for 1,100 feet down a 4.5-degree graded hill on a magnetic heading of 141 degrees. The aircraft's descent angle was computed to be 13 degrees, and the angle of impact was computed to be 8.5 degrees. There was evidence of a post-impact flash fire. Both engine and propeller assemblies were recovered and examined; the assemblies bore signatures consistent with engine power in a mid to high power range. The flaps and landing gear were retracted, indicating that the pilot did not attempt to land the airplane at the time of the accident. Flight control continuity was established, and control cable and push rods breaks exhibited signatures consistent with overload failures. There was no evidence of any pre-impact mechanical malfunction found during examination of the available evidence. The pilot had logged 2,775 total flight hours, of which 23 hours were in the accident airplane. Toxicology testing detected chlorpheniramine (an over-the-counter antihistamine that results in impairment at typical doses) and acetaminophen (an over-the-counter pain reliever and fever reducer often known by the trade name Tylenol and frequently combined with chlorpheniramine). No blood was available for tox testing, so it is not possible to accurately estimate the time of last use, nor determine if the level of impairment that these substances would have incurred during the flight. The airplane was not equipped with either a flight data recorder or a cockpit voice recorder, nor were they required by Federal Aviation Regulation (FAR). The impact damage to the aircraft, presence of dark night conditions, experience level of the pilot, and anomalous flight path are consistent with spatial disorientation.
Probable cause:
Failure to maintain clearance from terrain due to spatial disorientation.
Final Report:

Crash of an Antonov AN-12BP in Moscow: 7 killed

Date & Time: Jul 29, 2007 at 0417 LT
Type of aircraft:
Operator:
Registration:
RA-93912
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Moscow – Omsk – Bratsk – Komsomolsk-on-Amur
MSN:
4 3 417 09
YOM:
1964
Flight number:
VAS9655
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft departed Moscow-Domodedovo Airport on a cargo flight to Komsomolsk-on-Amur with intermediate stops in Omsk and Bratsk, carrying seven crew members and a load of 9,043 kilos of various equipments for the Gagarin Aircraft Manufacturing Plant in Komsomolsk. The aircraft took off from Domodedovo Airport runway 32C at 0415LT. While climbing at a height of about 70-75 metres and a speed of 295 km/h, the aircraft collided with a flock of birds that struck both engines n°3 and 4. Almost simultaneously, both right engines stopped and their respective propeller autofeathered. The aircraft lost speed, rolled to the right to an angle of 45° then entered an uncontrolled descent before crashing a wooded area located 4 km from the airport, bursting into flames. The aircraft was totally destroyed and all 7 occupants were killed.
Probable cause:
Loss of control and subsequent ground impact during initial climb following the failure of both right engines due to a bird strike.