Crash of an ATR72-212 in San Juan

Date & Time: May 9, 2004 at 1450 LT
Type of aircraft:
Operator:
Registration:
N438AT
Survivors:
Yes
Schedule:
Mayaguez - San Juan
MSN:
438
YOM:
1995
Flight number:
AA5401
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6071
Captain / Total hours on type:
3814.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
20
Aircraft flight hours:
19276
Aircraft flight cycles:
18086
Circumstances:
Flight 5401 departed Mayagüez, Puerto Rico, for San Juan about 14:15. The captain was the nonflying pilot for the flight, and the first officer was the flying pilot. The takeoff, climb, and en route portions of the flight were uneventful. At 14:37, as the flight approached the San Juan traffic area, the ATIS reported that winds were 060 degrees at 17 knots and gusting at 23 knots. Shortly thereafter, the captain briefed a Vref (the minimum approach airspeed in the landing configuration before the airplane reaches the runway threshold) of 95 knots and told the first officer to "stand by for winds." At 14:43 SJU Terminal Radar Approach Control cautioned the pilots of possible wake turbulence from a preceding Boeing. The captain told the first officer to slow down to about 140 kts. At 14:46, the local controller cleared the airplane to land on runway 08. The first officer turned the airplane left toward runway 08 and transitioned to the visual approach slope indicator. At 14:49, the captain stated, "you better keep that nose down or get some power up because you're gonna balloon." The airplane descended below the glideslope, causing a GPWS "glideslope" alert. The airplane was about 45 feet above ground level and traveling at 110 knots indicated airspeed when it crossed the runway 08 threshold. After the airplane crossed the runway threshold, the captain stated, "power in a little bit, don't pull the nose up, don't pull the nose up." At 14:49:39, the captain stated, "you're ballooning," and the first officer replied, "all right." The airplane touched down for the first time about 14:49:41 and about 1,600 feet beyond the runway 08 threshold with vertical and lateral loads of about 1.3 Gs and -0.10 G, respectively. Upon touchdown the captain stated, "get the power," and, 1 second later, "my aircraft." The first officer responded, "your airplane." The airplane had skipped to an altitude of about 4 feet and touched down again two seconds later about 2,200 feet beyond the runway 08 threshold. The airplane then pitched up to an angle of 9° while climbing to an altitude of 37 feet and the engine torque increased from 10 to 43 percent. About 14:49:49, the pitch angle decreased to -3°, and the engine torque started to decrease to 20 percent with the pitch angle decreasing to -10°. The airplane touched down a third time about 14:49:51 at a bank angle of 7° left wing down and about 3,300 feet beyond the runway 08 threshold and with vertical and lateral loads of about 5 Gs and 0.85 G. The ATR pitched up again to 24 feet and landed a fourth time about 14:49:56 (about 15 seconds after the initial touchdown) and about 4,000 feet beyond the runway 08 threshold. This time the airplane pitched down to -7° and that it was banked 29° left wing down. The airplane came to a complete stop on a grassy area about 217 feet left of the runway centerline and about 4,317 feet beyond the runway threshold.
Probable cause:
The captain’s failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around.
Final Report:

Ground explosion of a Douglas C-54B-1-DC Skymaster in Ganes Creek

Date & Time: May 7, 2004 at 2130 LT
Type of aircraft:
Operator:
Registration:
N44911
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ganes Creek – Fairbanks
MSN:
10461
YOM:
1945
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11250
Captain / Total hours on type:
5630.00
Copilot / Total flying hours:
7465
Copilot / Total hours on type:
1560
Aircraft flight hours:
29667
Circumstances:
The crew of the 4 engine airplane started its engines for a positioning flight from a remote mining airstrip. Following the startup of the engines, an explosion occurred in the left wing area aft of the number 1 engine firewall and number 1 auxiliary fuel tank. The airplane was parked next to the mine's fuel storage tank, and the pilot added power on the remaining engines to move away from the storage tank. Within seconds of beginning to move, the number 1 engine fell off the burning wing, followed by separation and aft folding of the outboard end of the left wing. The outboard end of the wing, however, was still attached via control cables. The pilot taxied the airplane about 200 feet, dragging the partially burning left wing segment to a pond of water and shut down the remaining engines. The crew evacuated with no injuries. Water was applied to the airplane until the fire was extinguished, about 3 1/2 hours later. NTSB and FAA personnel did not travel to the scene, and the airplane was not recovered from the mining strip. The airplane's left wing powerplant and fuel system consists of the number 1 and 2 engines. Each engine is separated from the wing by a firewall. Within the wing, from outboard to inboard, the fuel tank system consists of the number 1 fuel tank, the left wing auxiliary fuel tank, and the number 2 fuel tank. Each wet-wing type fuel tank contains a submerged electrical boost pump, sump drain valves and fuel quantity transmitters. The fuel system has selector valves, crossfeed valves, and shut-off valves for each tank. An FAA inspector examined portions of the airplane that the operator supplied. The inspector examined a portion of the upper wing surface that had been blown away from the airplane during the initial explosion. He noted that the inside of the upper wing surface, normally positioned over the auxiliary tank, was not charred or sooted. A separated portion of the lower wing surface, near the auxiliary boost pump, was sooted and charred. The aft side of the number 1 engine firewall was not charred. A portion of the number 1 engine nacelle was oily, but not sooted or charred. The operator located the auxiliary in-tank boost pump and sent it to the FAA. The boost pump impeller, encased in a small wire cage, was not melted and could be turned by hand. The body of the pump was sooted but not thermally damaged. Its wire connectors and one fuel line were melted. A smaller line, what appeared to be a return line, was not melted.
Probable cause:
A fuel tank explosion in the left wing auxiliary fuel tank, and subsequent fuel fire that occurred during engine start for an undetermined reason.
Final Report:

Crash of a Let L-410UVP in Jiech: 6 killed

Date & Time: May 7, 2004 at 1500 LT
Type of aircraft:
Operator:
Registration:
9XR-EF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jiech – Ayod
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft was chartered by a Sudanese Development Unit to deliver medics and other supplies to a school project in Ayod. Shortly after takeoff from Jiech Airport, while in initial climb, the twin engine aircraft stalled and crashed. One pilot and five passengers were killed while four other occupants were injured. Both pilots were New Zealand's citizens. It seems that the cargo shifted after takeoff, causing the aircraft to stall and crash.

Ground fire of a Transall C-160 in Fort-de-France

Date & Time: May 6, 2004 at 1358 LT
Type of aircraft:
Operator:
Registration:
R100/F-RAZR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Fort-de-France - Fort-de-France
MSN:
F100
YOM:
1970
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4306
Copilot / Total flying hours:
2564
Aircraft flight hours:
18530
Circumstances:
The aircraft was engaged in a local post maintenance test flight at Fort-de-France-Le Lamentin Airport, carrying five technicians and three crew members on behalf of the Escadron de Transport Outremer 58. After engine startup, the crew started to taxi when a fire erupted. The aircraft was stopped on the ramp and all eight occupants escaped uninjured. Within three minutes, fire bombers were on site and extinguished the fire. Nevertheless, the aircraft was damaged beyond repair.
Probable cause:
The accident was caused by electrical arcing at the power cable to a submersible fuel pump. This arcing occurred above the kerosene liquid inside the tank full of fuel vapors. The cable type used was chosen at the time of the design of the aircraft. Atmospheric conditions on the apron of Fort de France have raised the temperature of the reservoir beyond the flash point kerosene. The vapors contained in this tank were explosive, and the arc was enough to initiate the blast. As such, atmospheric conditions are a certain cause of environmental origin of the accident. The appearance of the arc is, in turn, has only technical causes:
- The quality of cable used and age are in fact responsible for the creation of the electric arc.
- The formation of the insulating sheath of this type of cable is not likely to ensure an absolute seal. This quality is also not claimed by its manufacturer.
Indeed, the analysis carried out show a porosity of electrical cable, even nine, therefore that it is soaked in kerosene. The presence of kerosene increases the phenomenon of porosity of old cables. Degradation characteristics of dielectric strength of the cable insulation explains the appearance of the arc. The accident occurred while the cable was over 19 years old. The fuel pumps wiring has never been a problem. But there has not been a cable that had reached the age of 19 years. The aging of the cable could still degrade the seal. Finally, maintaining this type of cable on the first C160 series until this accident was part of a complex process in which traceability has not been formally established. Doubts indeed appeared in 1969 on the quality of these cables, doubts that can be considered today as precursors. Measures had been adopted precisely to overcome these deficiencies. In this regard, the replacement of the fuel pump wiring of the second series C 160 of these cables with a newer type and considered more efficient is particularly significant. Its extension to the first series aircraft might have seemed relevant, and would probably have prevented the accident. The reasons which led to the maintenance of such cables on the C 160 series first held in both the human factor (underestimation of risk, lack of global view on the issue) and organizational factors, which can be seen as a lack of traceability of technical and logistic actions, a lack of consistency of the measures adopted, and probable deficiencies in the information flow.
Final Report:

Crash of a Swearingen SA227AC Metro III in Carepa: 5 killed

Date & Time: May 5, 2004 at 1300 LT
Type of aircraft:
Registration:
HK-4275X
Survivors:
Yes
Schedule:
Bogotá – Carepa
MSN:
AC-676
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
19335
Circumstances:
Following an uneventful flight from Bogotá-El Dorado Airport, the crew started the approach to Carepa-Los Cedros Airport, the copilot was the pilot-in-command. On final approach, the captain took over controls and continued the descent when the GPWS alarm sounded seven times. For unknown reasons, the captain failed to respond to this situation and did not proceed with any corrective actions. On short final, at a height of about 200 feet, one of the engine failed. The crew failed to follow the published procedures, causing the aircraft to stall and to crash about 100 metres short of runway 33. Two passengers were seriously injured while five other occupants were killed.
Probable cause:
The following findings were identified:
- Poor judgement of distance, speed, altitude and the obstacle clearance during the final approach,
- Attempting the operation beyond the experience and the high level of competence required by the crew,
- Encountering unforeseen circumstances exceeded the capacity of the crew,
- Diverting attention on the operation of the aircraft,
- Lack of approved procedures, directives and instructions,
- The absence of CRM procedures and low situational awareness,
- The lack of evasive action when the ground proximity warning system's alarm sounded,
- The sudden loss of power in one of the engines,
- The wrong use of the world's major flight to maintain directional control,
- The activation of the Stall Avoidance System (SAS) on the control column, moving it forward when the plane was at low altitude.

Crash of a Douglas DC-10-30F in Bogotá

Date & Time: Apr 28, 2004 at 0356 LT
Type of aircraft:
Operator:
Registration:
N189AX
Flight Type:
Survivors:
Yes
Schedule:
Miami – Bogotá
MSN:
48277
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
77864
Aircraft flight cycles:
12224
Circumstances:
Following an uneventful cargo flight from Miami-Intl Airport on behalf of Lineas Aéreas Suramericanas, the crew started a night approach to Bogotá-El Dorado Airport. On final, the aircraft was unstable and too low when the GPWS alarm sounded five times. The captain increased engine power and elected to gain height, causing the aircraft to continue over the glide. At an excessive speed of 180 knots, the aircraft landed 1,500 feet past the runway 13L threshold (runway 13L is 3,800 metres long). After touchdown, the crew started the braking procedure but unable to stop within the remaining distance, the aircraft overran. It lost its undercarriage, collided with the ILS equipment, lost both engines n°1 and 3 and eventually came to rest few hundred metres further in a grassy area. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Departure from runway 13 left the El Dorado airport as a result of a landing with a speed of 180 knots and 1500 feet from the threshold, during which the spoilers were not used and in which there was hydroplaning by the main landing gear making the braking action less than expected. The decision of the crew to continue the approach despite the fact that this was not stabilized in accordance with the criteria described in the manual of operations of the airline. The omission of points in the checklist and call out from the crew that resulted in a lower alert situation facing the parameters of the approach and monitoring the operation of key systems such as the extension of spoilers after the landing. The non-response to the ground proximity warning system that is sounded for at least five times during the final approach in two different modes.

Crash of a Fokker F27 Friendship 500 in Melo

Date & Time: Apr 27, 2004 at 0415 LT
Type of aircraft:
Operator:
Registration:
N715FE
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires – Porto Alegre – Campinas
MSN:
10468
YOM:
1971
Flight number:
FDX7145
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Buenos Aires-Ezeiza-Ministro Pistarini Airport on a night cargo service to Campinas-Viracopos with an intermediate stop in Porto Alegre. While cruising at an altitude of 17,000 feet, smoke was detected in the cargo compartment. The crew elected to extinguish the fire but without success. The crew contacted ATC, declared an emergency and attempted to divert to Montevideo Airport but ATC suggested the crew to divert to Melo which was the nearest airport. As this airfield was closed to traffic at this time, ATC contacted a night guard who switched on the runway lights and alerted the local emergency services. The aircraft landed 340 metres past the runway 07 threshold and stopped 640 metres further. The crew evacuated via the cockpit windows and was uninjured. The aircraft was damaged beyond repair.
Probable cause:
Numerous oil samples, plant tissues, and several animals that were transported, would have reacted on contact with an exothermic chemical reaction and associated combustion. The event originated with the spilling of liquid from containers not suitable for differential pressure, with little excess capacity for expansion and filled with indiscriminate materials. Low stringency in filling forms for description of product delivered for shipment in company offices and little control or careless handling of the load would have contributed to the occurrence of the accident.

Ground accident of a McDonnell Douglas MD-82 in Trieste

Date & Time: Apr 20, 2004 at 1038 LT
Type of aircraft:
Operator:
Registration:
I-DAWR
Survivors:
Yes
Schedule:
Rome – Trieste
MSN:
49208/1190
YOM:
1985
Flight number:
AZ1357
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
92
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7988
Captain / Total hours on type:
3800.00
Copilot / Total flying hours:
5724
Aircraft flight hours:
41745
Aircraft flight cycles:
34235
Circumstances:
Following an uneventful flight from Rome-Ciampino Airport and a normal landing at Trieste-Ronchi dei Legionari Airport runway 09, the crew vacated the runway and continued via taxiway Bravo to the apron. The copilot was the pilot-in-command and he was facing sun while approaching the ramp. At the last moment, the captain noticed a dump truck on the right side of the taxiway. He took over controls and elected to turn to the left but the aircraft collided with the truck. The outer part of the right wing was torn off for about 3,5 metres and the fuselage was bent. Also, a fuel tank ruptured, causing a spill on the taxiway. The captain immediately stopped the airplane and all 96 occupants evacuated safely. It appeared that construction works were in progress near the taxiway Bravo. A Notam was not issued about this and the tower controller had not informed the crew either.
Probable cause:
The analysis of the technical, operational and organizational context in which the event took place (impact of the end of the right wing of the aircraft, during taxiing, against the rear body of a truck that was parked for work within the protection area of the taxiway that leads from the Bravo connection to the parking area) has allowed to determine the following causes, which are attributable to human and environmental factors.
- Failure to close the Bravo taxiway with the issue of the relative NOTAM of the works in progress.
- Failure of the Torre control to provide the pilots with essential information on the condition of the airport, as provided for by ICAO in ICAO Doc. 4444 PANS-ATM.
- Vertical and horizontal ground signs do not correspond to those specified in ICAO Annex 14.
- Failure to comply with the ENAC circular (APT-11), applicable for the type of work in progress at the airport.
- Insufficient surveillance of the airport area affected by the works by ENAC and the airport management company Aeroporto FVG.
- Lack of an airport Safety Management System .
- Inadequate surveillance of the external space during taxiing by the flight crew, resulting in incorrect assessment of the position of the aircraft with respect to the obstacle.
Final Report:

Crash of a Cessna 404 Titan II in Nampula: 2 killed

Date & Time: Apr 20, 2004
Type of aircraft:
Operator:
Registration:
ZS-NVD
Flight Phase:
Survivors:
No
MSN:
404-0667
YOM:
1980
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Nampula Airport, while in initial climb, the aircraft went out of control and crashed, killing both occupants. They were engaged in a geological mission on behalf of the Mozambican government in the north part of the country.

Crash of a Beechcraft A100 King Air in Chibougamau

Date & Time: Apr 19, 2004 at 1018 LT
Type of aircraft:
Operator:
Registration:
C-FMAI
Survivors:
Yes
Schedule:
Quebec - Chibougamau
MSN:
B-145
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11338
Captain / Total hours on type:
2600.00
Copilot / Total flying hours:
1176
Copilot / Total hours on type:
400
Circumstances:
The Beechcraft A100, registration C-FMAI, operated by Myrand Aviation Inc., was on a chartered instrument flight rules flight from QuÈbec/Jean Lesage International Airport, Quebec, to Chibougamau/Chapais Airport, Quebec, with two pilots and three passengers on board. The copilot was at the controls and was flying a non-precision approach for Runway 05. The pilot-in-command took the controls less than one mile from the runway threshold and saw the runway when they were over the threshold. At approximately 1018 eastern daylight time, the wheels touched down approximately 1500 feet from the end of Runway 05. The pilot-in-command realized that the remaining landing distance was insufficient. He told the co-pilot to retract the flaps and applied full power, but did not reveal his intentions. The co-pilot cut power, selected reverse pitch and applied full braking. The aircraft continued rolling through the runway end, sank into the gravel and snow, and stopped abruptly about 500 feet past the runway end. The aircraft was severely damaged. None of the occupants were injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was positioned over the runway threshold at an altitude that did not allow a landing at the beginning of the runway, and this, combined with a tailwind component and the wet runway surface, resulted in a runway excursion.
2. Failure to follow standard operating procedures and a lack of crew coordination contributed to confusion on landing, which prevented the crew from aborting the landing and executing a missed approach.
3. The pilot-in-command held several management positions within the company and controlled the pilot hiring and dismissal policies. This situation, combined with the level of experience of the co-pilot compared with that of the pilot-in-command, had an impact on crew cohesiveness.
Findings as to Risk:
1. The pilot-in-command of C-FMAI decided to execute an approach for Runway 05 without first ensuring that there would be no possible risk of collision with the other aircraft.
2. The regulatory requirement to conform to or avoid the traffic pattern formed by other aircraft is not explicit as to how the traffic pattern should be avoided, in terms of either altitude or distance, which can result in risks of collision.
3. The regulations do not indicate whether the missed approach segment should be considered part of the traffic pattern; this situation can lead pilots operating in uncontrolled airspace to believe that they are avoiding another aircraft executing an instrument approach when in reality a risk of collision exists.
Final Report: