Crash of a Boeing 747-212B in Düsseldorf

Date & Time: Jan 24, 2005 at 0605 LT
Type of aircraft:
Operator:
Registration:
N808MC
Flight Type:
Survivors:
Yes
Schedule:
Dubaï – Düsseldorf
MSN:
21048
YOM:
1975
Flight number:
GTI8995
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
2300.00
Copilot / Total flying hours:
14600
Copilot / Total hours on type:
3000
Aircraft flight hours:
92024
Aircraft flight cycles:
22782
Circumstances:
The aircraft departed Dubai on a cargo flight to Düsseldorf with three crew members on board. Following an uneventful flight, the crew established radio contact with Düsseldorf Radar at 0543LT. The crew were told that runway 23L was in use. Two minutes later the radar controller contacted flight 8995: "I just talked to the tower and ah for the time being braking action on all parts of the runway is supposed to be good. They are measuring again right now because it started to snow again and I'll keep you advised." The flight was then cleared to descend to FL80. The flight crew decided to set the autobrakes for landing on Medium, to account for the snow. At 05:50 the radar controller again contacted the flight about the current weather circumstances: "...latest update on the weather situation ahm the friction tester has reported braking action to be good for the moment however as its continuing to snow they are ah afraid that it might worsen, so they are going to do another friction test right before you land." In the following minutes the flight was given descent instructions and vectors for an approach to runway 23L. At 05:54 the controller radioed: "weather update we now have a surface wind of three four zero degrees eleven knots, that's slight tail wind component by two knots. Visibility is down to one thousand five hundred meters, still in snow showers and ah cloud base is now five hundred feet only." The flight was subsequently cleared for the approach. At 05:57 the radar controller instructed the crew to contact Düsseldorf Tower. The Tower controller stated: "Good morning,... we are just waiting for the braking action values from the friction tester stand by a second. The surface wind is actually three three zero degrees one two knots." Two minutes later the controller radioed: "... the braking action was measured to be medium at all parts. And ah the visibility dropped right now due to the heavy snow showers at the field ah. The RVR value at the touchdown zone is presently nine hundred meters, at the mid-point one thousand one hundred meters and ah stop end one thousand one hundred meters." At that moment the flight was 3,5 nautical miles out. The flight was subsequently cleared to land. The airplane touched down about 1700 ft (518 m) past the runway threshold. Ground spoilers and thrust reversers deployed and the autobrakes activated. Still the airplane did not decelerate as expected and the pilot applied manual braking. The airplane failed to stop and overran the runway end. It collided with ILS equipments, which caused a fire in engines n°2 and 3. All three crew members evacuated safely and the aircraft was considered as damaged beyond repair.
Probable cause:
The accident is attributable to the fact that the braking values transmitted to the crew did not meet the conditions that had arisen as a result of heavy snowfall since the last measurement on the runway.
The following contributing factors were identified:
- Fast changing weather,
- The lack of an in all weather conditions reliable measurement method for the determination of braking coefficient.
Final Report:

Crash of an Antonov AN-8 in Kongolo

Date & Time: Jan 22, 2005 at 1300 LT
Type of aircraft:
Registration:
EL-WVA
Flight Type:
Survivors:
Yes
Schedule:
Goma – Bukavu – Kindu – Kongolo
MSN:
OG 34 40
YOM:
1960
Location:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Kongolo Airport, the aircraft crashed on houses located 100 metres short of runway. All 10 occupants were injured while there were no casualties on the ground. The aircraft was completing a humanitarian mission from Goma with intermediate stops in Bukavu and Kindu on behalf of the French NGO "Solidarités". The leasing contract stipulated that no passengers were authorized to board.

Crash of a Cessna 421C Golden Eagle III in Olathe: 5 killed

Date & Time: Jan 21, 2005 at 0943 LT
Operator:
Registration:
N844JK
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Olathe – Zephyrhills
MSN:
421C-0681
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6064
Aircraft flight hours:
2957
Circumstances:
The airplane received substantial damage on impact with trees, terrain, and a residence about one mile from the departure airport during instrument meteorological conditions. The airport elevation was 1,096 feet mean sea level. The personal flight was operating on an instrument flight rules (IFR) flight plan with a filed equipment suffix designating that the airplane was equipped with a Global Positioning System. Airplane records indicate that the airplane was equipped with a GPS but was not approved for IFR navigation. The pilot was issued a departure clearance to 3,000 feet and heading of 130 degrees. Radar data indicates that the airplane leveled off at an altitude approximately 2,000 feet during a 32 second period while executing a right turn to the assigned heading. Witnesses reported that the airplane impacted terrain in a right wing nose low attitude. Wreckage distribution and ground scarring was indicative of a high-speed impact with terrain. No anomalies that would have precluded normal operation of the airplane were noted. The calculated airplane weight was approximately 597 lbs above the maximum gross weight of the airplane.
Probable cause:
The pilot's failure to maintain adequate altitude/clearance during cruise flight, resulting in collision with trees. Contributing factors were the low altitude and low ceiling.
Final Report:

Crash of a Gulfstream GII in Logan

Date & Time: Jan 19, 2005 at 2030 LT
Type of aircraft:
Operator:
Registration:
N74RQ
Survivors:
Yes
Schedule:
Kansas City – Logan
MSN:
113
YOM:
1972
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5320
Captain / Total hours on type:
1253.00
Copilot / Total flying hours:
8000
Copilot / Total hours on type:
3000
Aircraft flight hours:
12011
Circumstances:
The captain stated they had flown the GPS approach to runway 35. When they did not see the runway or runway environment they initiated a missed approach. During the missed approach, they were able to see the first 4 to 5 thousand feet on the approach end of runway 17. They "elected to circle to the north west to set up for a visual approach to runway 17." The captain stated that the approach was "slightly high and as a result, the flare was a bit higher than normal." The airplane entered the fog layer just prior to touchdown. The captain stated that during the landing flare the airplane had drifted to the left and "the aircraft settled onto the runway to the left of centerline and shortly thereafter the left main gear impacted a snow berm." The airplane turned hard to the left and departed the runway. The nose gear separated, the radome was crushed and the cockpit pressure bulkhead was broken open. The routine aviation weather report (METAR) at LGU reported the weather as follows: wind, calm; visibility, 1/4 statute mile in freezing fog; sky condition, vertical visibility 100 feet agl; temperature, minus 7 degrees Celsius (C), dewpoint, minus 7 degrees C; altimeter, 30.45 inches.
Probable cause:
The pilot's improper IFR operation by which he failed to comply to the missed approach procedure, and his improper evaluation of the weather resulting in an encounter with fog and his loss of visual contact with the runway during the landing.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Keene: 1 killed

Date & Time: Jan 13, 2005 at 2215 LT
Operator:
Registration:
N49BA
Flight Type:
Survivors:
No
Schedule:
Bangor – Manchester
MSN:
110-301
YOM:
1980
Flight number:
BEN2352
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2292
Captain / Total hours on type:
338.00
Aircraft flight hours:
39466
Circumstances:
En route to the company's home airport, the twin-engine airplane either experienced a loss of power to the right engine, or the pilot decided to shut the engine down. Although the home airport had night visual meteorological conditions, and there was no evidence of any malfunction with the remaining engine, the pilot opted to fly a night precision instrument approach to an airport 45 nautical miles closer, with a 1-mile visibility and a 100-foot ceiling. Unknown to the pilot, there was also fog at the airport. The pilot did not advise or seek assistance from air traffic control or the company. When the airplane broke out of the clouds, it was not stable. Approaching the runway, at full flaps and exceeding the 25 percent maximum for a go-around, the pilot added full power to the left engine. The high power setting, slow airspeed, and full flaps combination resulted in a minimum control speed (Vmc) roll. No determination could be made as to why the right engine was inoperative, and there were no mechanical or fuel-related anomalies found that would have precluded normal operation.
Probable cause:
The pilot's improper decision to attempt a single-engine missed approach with the airplane in a slow airspeed, full flap configuration, which resulted in a minimum control speed (Vmc) roll. Contributing factors included an inoperative engine for undetermined reasons, the pilot's in-flight decision to divert to an airport with low ceilings and visibility while better conditions existed elsewhere, the pilot's failure to advise or seek assistance from air traffic control or his company, and the low cloud ceilings, fog, and night lighting conditions.
Final Report:

Crash of a PZL-Mielec AN-2 in Tura: 9 killed

Date & Time: Jan 13, 2005 at 1720 LT
Type of aircraft:
Registration:
RA-62597
Survivors:
No
Schedule:
Vanavara - Tura
MSN:
1G177-44
YOM:
1978
Flight number:
TUR9368
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
Following an uneventful flight from Vanavara, the crew started the descent by night to Tura Airport. Weather conditions were marginal with a visibility of 3,500 metres and light snow. After being cleared to land, the crew continued the approach. At a speed of 160 km/h, the crew initiated a right turn. In a 10° nose down and a right bank of 40°, the aircraft impacted trees and crashed in a snow covered forest located 9,6 km southeast of the airport. The wreckage was found a day later near the Bazhenov River and all nine occupants were killed, among them the regional director of the Department of Transport and the vice-governor of the Evenkiya region.
Probable cause:
Controlled flight into terrain following a wrong altimeter setting. The lack of visibility was a contributing factor.

Crash of a Beechcraft E90 King Air in Rawlins: 3 killed

Date & Time: Jan 11, 2005 at 2145 LT
Type of aircraft:
Operator:
Registration:
N41WE
Flight Type:
Survivors:
Yes
Schedule:
Steamboat Springs – Rawlins
MSN:
LW-280
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3778
Captain / Total hours on type:
414.00
Aircraft flight hours:
8921
Circumstances:
The air ambulance was dispatched from Steamboat Springs, Colorado (SBS), to pick up and transport a patient in serious condition from Rawlins Municipal Airport/Harvey Field (RWL) to Casper, Wyoming. Approaching RWL, the pilot initiated a right turn outbound to maneuver for the final approach course of the VOR/GPS approach to runway 22. On the inbound course to the airport, the airplane impacted mountainous terrain, approximately 2.5 nautical miles east-northeast of the airport. The airplane, configured for landing, struck the terrain wings level, in a 45-degree nose-down dive, consistent with impact following an aerodynamic stall. Approximately 5 minutes before the accident, RWL reported broken ceilings at 1,100 and 1,800 feet above ground level (agl), 3,100 feet agl overcast, visibility 2.5 statute miles with light snow and mist, temperature 33 degrees Fahrenheit (F), dew point 30 degrees F, winds 240 degrees at 3 knots, and altimeter 29.35 inches. Before departing SBS, the pilot received a weather briefing from Denver Flight Service. The briefer told the pilot that there was a band of light to moderate snow shower activity halfway between Rock Springs and Rawlins, spreading to the northeast. The briefer told the pilot there were adverse conditions and flight precautions along his route for occasional mountain or terrain obscurations. The pilot responded that he planned to fly instrument flight rules for the entire flight. The National Weather Service, Surface Analysis showed a north-south stationary front positioned along the front range of the Rocky Mountains beginning at the Wyoming/Montana border and extending south into north-central Colorado. Station plots indicated patchy snow over western Colorado and Wyoming. The most recent AIRMET reported, "Occasional moderate rime or mixed icing in clouds and precipitation between the freezing level and flight level 220." The freezing level for the area encompassing the route of flight began at the surface. Witnesses in the vicinity of RWL reported surface weather conditions varying from freezing rain to heavy snow. An examination of the airplane showed clear ice up to 1 ½ inches thick adhering to the vertical stabilizer, the left and right wings, the right main landing gear tire, and the right propeller. The airplane's aerodynamic performance was degraded due to the ice contamination, leading to a stall. An examination of the airplane's systems revealed no anomalies. A human factors review of interviews and other materials showed insufficient evidence that the company placed pressure on the pilot to take the flight; however, the review did not rule out the pilot inducing pressure on himself. FAA Advisory Circular (AC) 135-15, Emergency Medical Services/Airplane (EMS/A) addresses several subject areas not practiced by the operator, including, "Additional considerations when planning IFR flights include the following: (1) Avoid flight in icing weather whenever possible."
Probable cause:
The pilot's inadvertent flight into adverse weather [severe icing] conditions, resulting in an aerodynamic stall impact with rising, mountainous terrain during approach. A factor contributing to the accident was the pilot's inadequate planning for the forecasted icing conditions.
Final Report:

Crash of a McDonnell Douglas MD-83 in Cali

Date & Time: Jan 8, 2005 at 1548 LT
Type of aircraft:
Operator:
Registration:
VP-BGI
Survivors:
Yes
Schedule:
Cartagena – Cali
MSN:
49940
YOM:
1990
Flight number:
RPB7463
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
41329
Aircraft flight cycles:
18037
Circumstances:
After landing at Cali-Alfonso Bonilla Aragón Airport, the aircraft encountered difficulties to decelerate properly. It overrun the runway 19 (which is 9,842 feet long), lost its undercarriage, collided with the perimeter fence and came to rest on its belly. Six passengers were slightly injured while all other occupants escaped unhurt. The aircraft was damaged beyond repair.
Probable cause:
The accident was caused by a chain of errors and mistakes which began by accepting and carrying out a hasty descent that led to the omission of key points in the checklist such as the arming of the spoilers, excessive descent rate and speed and a configuration that led to faulty placement of the aircraft on the runway in abnormal conditions and 862 meters from the normal touchdown point. These conditions caused a vibration of the right main landing gear that could not be controlled by the Shimmy Damper, allowing higher loads to the strength of the undercarriage, which broke.

Crash of a Boeing 737-2A9C in Banda Aceh

Date & Time: Jan 4, 2005 at 0200 LT
Type of aircraft:
Operator:
Registration:
PK-YGM
Flight Type:
Survivors:
Yes
MSN:
20206/249
YOM:
1970
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a cargo flight to Banda Aceh, taking part to relief operation following the recent tsunami that affected the Aceh province. After landing by night, the crew started the braking procedure when the aircraft collided with a buffalo. Upon impact, the left main gear was torn off and the aircraft slid for few dozen metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Collision with a buffalo upon landing.

Crash of a Cessna 551 Citation II/SP in Ainsworth

Date & Time: Jan 1, 2005 at 1120 LT
Type of aircraft:
Operator:
Registration:
N35403
Flight Type:
Survivors:
Yes
Schedule:
Reading - Ainsworth
MSN:
551-0029
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2200
Captain / Total hours on type:
475.00
Aircraft flight hours:
5870
Circumstances:
The twin-engine corporate jet impacted terrain while maneuvering to land after a global positioning system (GPS) approach. The pilot reported that the airplane entered icing conditions during the approach and that the airplane descended out of instrument meteorological conditions between 300-400 feet above ground level (agl). The pilot reported that his windshield had become obscured by ice accumulation during the approach and that he "had difficulty seeing the runway." The pilot elected to land the airplane instead of executing the published missed-approach procedure. The airplane impacted terrain 439 feet short of the runway threshold while in a right turn. After the accident, there was ice accumulation on all booted airframe surfaces measuring 2-4 inches wide and 1/4 to 3/8 inch thick. The upper portions of the windscreens were contaminated with ice measuring about 3/8 inch thick. The remaining airframe portions, including the heated surfaces, were free of ice accumulation. The windshield bleed air switch was selected on "High" with the pilot's side windshield heat control knob approximately mid-range. Windshield alcohol was selected "On", but the alcohol reservoir was still full upon inspection. At the time of the accident, there was an overcast ceiling of 500 feet agl, 1-3/4 statute mile visibility with mist, and an outside temperature of -08 degrees Celsius. The published minimum descent altitude (MDA) for the GPS runway 17 approach is 500 feet agl, for an airplane equipped with a lateral navigation only GPS receiver. The pilot held a private pilot certificate with multi-engine land, instrument airplane, and Cessna 500 type rating. The pilot reported having 2,200 hours total flight time and 475 hours in the same make/model as the accident airplane.
Probable cause:
The pilot's decision to continue below the minimum descent altitude (MDA) and his failure to fly the published missed-approach procedure. A factor to the accident was the pilot's improper use of windshield heat which resulted in the windshield becoming obscured with ice during the instrument approach in icing conditions.
Final Report: