Crash of an Antonov AN-12 in Heglig

Date & Time: Apr 30, 2002
Type of aircraft:
Operator:
Registration:
ST-AQP
Flight Type:
Survivors:
Yes
Schedule:
Khartoum - Heglig
MSN:
4 3 423 05
YOM:
1964
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Heglig Airport, at a height of about 60 feet, the aircraft collided with a flock of birds coming from the right side. The engine n°4 failed, the aircraft rolled to the right, lost height and struck the ground short of runway threshold. Upon impact, the undercarriage were torn off and the aircraft crash landed. All four crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control on final approach after the failure of the engine n°4 following a bird strike.

Crash of a Boeing 707-366C in Kinshasa

Date & Time: Apr 26, 2002
Type of aircraft:
Operator:
Registration:
9Q-CKB
Flight Type:
Survivors:
Yes
Schedule:
Johannesburg - Kinshasa
MSN:
19844
YOM:
1968
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 24 at Kinshasa-N'Djili Airport in poor weather conditions, the aircraft went out of control, veered off runway to the right, lost its right main gear and came to rest few dozen metres further. All three crew members escaped with minor injuries while the aircraft was damaged beyond repair. Weather was poor at the time of the accident with heavy rain falls and crosswinds.

Crash of an Antonov AN-72 in Wamena

Date & Time: Apr 21, 2002 at 0913 LT
Type of aircraft:
Operator:
Registration:
ES-NOP
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
36572010905
YOM:
1980
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7744
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
8500
Copilot / Total hours on type:
100
Aircraft flight hours:
1897
Aircraft flight cycles:
1376
Circumstances:
At 23:40 UTC / 08:40 LT (WIT) on Sunday April 21, 2002, the ES-NOP departed Sentani Airport, Jayapura, bound for Wamena. The aircraft, an Antonov AN-72, was being operated by PT Trigana Air Services as a cargo carrying charter transport flight. The flight crews of four included three cockpit crew personnel and a loadmaster. The flight was the third flight of eight flights planned for the day between Sentani Airport and Wamena airport. The first flight departed Sentani airport at 21:05 UTC / 06:05 LT. Arriving at Wamena at 21:40 UTC / 06:40 LT. The return flight from Wamena bound for Sentani, departing Wamena at 22:22 UTC/ 07:22 LT arrived at Sentani at 22:52 UTC/07:52 LT. The flights were reported normal, and the weather along the route was reported clear. The third return flight, from Sentani to Wamena departed Sentani at 23:40 UTC / 08:40 LT carrying a load of 7,481 kg. The weather at Jayapura and along the route was clear. The cruise altitude during the flight was 16,000 ft. After waypoint ‘Maleo’ the airplane over-flew the so called ‘north-gap’ and the descent was initiated while passing the ‘pass valley’. Three other airplanes were reported to be in the area, one Fokker F27 PK-YPQ which was enroute from Wamena airport to Jayapura, and two Antonov A26 aircraft, registration ER-AFQ and ER-AFE. Flying over ‘Yiwika’ 7 Nm from Wamena airport, and descending through 12,000 ft with speed of 330 km/hr, the ES-NOP overtook the ER-AFE. The flight crew had the runway in sight. The PIC acting as pilot flying, flew an ‘S’ approach pattern during the final flight path of Wamena airport. (arriving Wamena 24:15 UTC/09:15 LT). On final and at an altitude of 100 meters, the airplane was lined up to the runway 15-center line. The airplane touched down while still within the touchdown zone. The airplane bounced twice, the second and last bounce reported to be more severe than the first one. The airplane rolled down the runway, with the flight crew noticing an unusual nose down attitude. The PIC/Pilot Flying applied reverse power and brakes, controlling the aircraft by using rudder inputs. During the roll, the loadmaster, sitting behind the PIC’s seat saw black smoke coming from the floor of the forward side of the cargo compartment. The crew reported that the smoke hurt their eyes. The airplane decelerated with smoke emitted from the forward cargo compartment. After stopping, the loadmaster opened the airplane door taking the extinguisher to extinguish the fire. The PIC shut down the engines after the airplane came to a standstill then opened the left cockpit window. PIC then left the cockpit assisting the loadmaster extinguishing the fire, the F/O completed the shutdown procedure, as the smoke blocked out his vision. The Flight Engineer attempted unsuccessfully opened the overhead emergency exit. The F/O and Flight Engineer then evacuated through the left cockpit window, while the PIC and loadmaster exited through the door. Observing the occurrence, and as the crash bell was unserviceable, the ATC on duty called the Deputy Chief of the airport, and alerted the fire fighting brigade. The fire fighting personnel failed to start the fire truck, and after recharging the truck’s battery for about 10 minutes reattempt to start for a second time. This attempt again failed, and the battery was again recharged, while fire fighting personnel ran the airplanes final position carrying portable fire extinguisher. After another ten minutes of battery charging, the fire fighting truck was finally started, immediately proceeding to the accident site. After a refill of the fireextinguishing agent the fire was finally extinguished. Firefighting personnel extinguished the fire in about 30 minutes time. The airplane was seriously damaged, with the front side of the airplane completely burnt out, the fire cutting a hole from behind the cockpit roof until approximately the middle of the cabin in front of the roof. The cargo was totally consumed by fire. No one was injured during the accident. After the occurrence, Wamena airport was closed for Fokker 27 or bigger aircraft but opened for DHC-6 (Twin Otter) or smaller aircraft. The NTSC investigator team embarked to Wamena on that day (Sunday, April 21 2002). On Monday, April 22 2002, at 02.00 PM (LT), the investigator team give the clearance to remove the aircraft from the runway, at 05.00 PM (LT) the airport authority personnel started the efforts to removed the aircraft by big back hoe, at 08.30 PM (LT) ES-NOP has cleared from runway. On Tuesday April 23rd 2002, the Wamena airport activities back to normal as usual.
Probable cause:
The following findings were identified:
- The crew performed visual approach to Wamena airport at airspeed exceeded the provision on AN-72 manual.
- The crew failure to estimate distance to start the final turn properly made the unable to decrease speed and therefore unable to extend flap to landing configuration.
- The high rate of descent and flap configuration upon final activated GPWS warning.
- The landing (touchdown) speed was exceeded the prescribed value in the AN-72 manual and the aircraft has slight drift angle at first touchdown.
- After the first touch the aircraft bounced three times. This and the fact that the aircraft was at high loading lead to the failure of the nose gear.
- The fire was caused by the heat from the friction as the aircraft components skidding on the runway and the presence of hydraulic fluid leaking from the damaged system.
- There is no indication of any malfunction in the aircraft system that could contribute to the accident.
- There is no indication of misconduct in the maintenance of the aircraft that could contribute to the accident.
- The fire brigade at Wamena airport was not in ready condition at the time of the accident, which leads to failure to extinguish the fire in time. The failure resulted in heavy fire damage on the aircraft.
- The fire brigade was not able the handle the fire due to non-serviceable equipment and lack of training for the personnel.
- Government check pilot need to perform close supervision (onboard the flight or give exams) to AN72 crew according to CASR 121 and CASR 61. By the time the report is written, the investigation could not find the necessary document that stated whether PT. Trigana has the authority to represent the government on the matter.
Safety Threats:
It is to be noted that there is blank radio transmission area at the gap. The Aviation Safety of Department of Communication plan to install relay antenna to resolve the problem. In the meantime, the authority required all aircraft passing the gap to perform blind transmission. It is to be noted that the lack of type certificate made the investigation progress very slow. The difficulty was due to lack of knowledge in the Indonesian authority on the technical aspect of the aircraft. Indonesian DGAC stated that the special permit for non-TC aircraft to operate in Papua will only valid until 2004.
Final Report:

Crash of an Antonov AN-32A in Popayán: 3 killed

Date & Time: Apr 19, 2002 at 0853 LT
Type of aircraft:
Operator:
Registration:
HK-4171X
Flight Phase:
Survivors:
Yes
Schedule:
Popayán – Medellín
MSN:
2508
YOM:
1991
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9798
Captain / Total hours on type:
1548.00
Copilot / Total flying hours:
1069
Copilot / Total hours on type:
855
Aircraft flight hours:
3153
Circumstances:
The aircraft was chartered to transfer groups of prisoners from Medellín to Popayán on behalf of the National Penitentiary and Prison Institute. Fifty prisoners just disembarked at Popayán Airport when the crew departed on a ferry flight to Medellín for a second similar rotation. Popayán Airport is located at an altitude of 1,733 metres and its runway is 1,906 metres long. For unknown reasons, the crew decided to start the takeoff procedure from the intersection, reducing the available takeoff distance to 910 metres. Also, the flaps were deployed to an angle of 25° instead of 15° and the engine power was set at 95% instead of 100% as stipulated in the company procedures for airport located above the altitude of 1,400 metres. During the takeoff roll, at a distance of 150 metres from the runway end, the pilot realized he could not make it so he rejected the takeoff procedure and started an emergency braking manoeuvre. Unable to stop within the remaining distance, the aircraft overran, struck trees and came to rest, broken in two. Three passengers were killed while five other occupants were injured.
Probable cause:
Improper execution by the crew by not following the procedures, instructions and manuals of the aircraft manufacturer and approved to the SELVA company by the UAEAC, specifically when attempting to perform a takeoff in a wrong configuration, with a reduced power setting and an insufficient runway length for the execution of the procedure.
Final Report:

Crash of a Let L-410UVP-E9 in Ngerende

Date & Time: Apr 17, 2002
Type of aircraft:
Registration:
5Y-UAS
Flight Phase:
Survivors:
Yes
Schedule:
Ngerende – Nairobi
MSN:
84 13 24
YOM:
1984
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a dirt strip (3,900 feet long) at Ngerende, an impala crossed the runway. To avoid a collision, the crew pulled up the control column and started the rotation. Because the airspeed was insufficient, the pilot-in-command put the nose down to gain speed when the aircraft struck the ground and crash landed in a field. All 17 occupants were rescued, among them a passenger was slightly injured. The aircraft was damaged beyond repair.

Crash of an Avro 748-372-2B in Sun City

Date & Time: Apr 16, 2002 at 1334 LT
Type of aircraft:
Operator:
Registration:
ZS-OLE
Survivors:
Yes
Schedule:
Skukuza - Sun City
MSN:
1796
YOM:
1982
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3846
Captain / Total hours on type:
755.00
Circumstances:
During the flight from Skukuza to Pilanesberg the aircraft developed a hydraulic problem, resulting in a complete hydraulic failure. However, a safe landing was carried out at Pilanesberg on Runway 23. Shortly after the landing the pilot shut down both engines, but maintained the runway heading for approximately 2000m, before the aircraft veered off to the left of the runway where it entered a ditch, 75m from the runway edge, where it finally stopped. There were no injuries, but the aircraft sustained extensive damage and substantial damage was caused to the perimeter fence around the airport. Both the pilot and the co-pilot were correctly licenced and type rated on the aircraft. Apart from the CVR, which was inoperative at the time of the accident and a leaking L/H hydraulic pump, it would appear that the aircraft was correctly maintained. Fine weather conditions prevailed at the time of the accident. The pilot informed Pilanesberg ATC of a complete hydraulic failure, but did not declare an emergency. The pilot failed to switch off the Nose Wheel Steering after touchdown and also shut down both hydraulic cut-off switches. The Emergency Checklist does not provide for a complete hydraulic failure.
Probable cause:
The accident resulted from a complete hydraulic failure, probably as a result of a leak on the L/H engine pump, which was not dealt with properly. Contributing to this was an incomplete emergency checklist.
Final Report:

Crash of a Boeing 767-2J6ER in Busan: 129 killed

Date & Time: Apr 15, 2002 at 1121 LT
Type of aircraft:
Operator:
Registration:
B-2552
Survivors:
Yes
Schedule:
Beijing - Busan
MSN:
23308
YOM:
1985
Flight number:
CA129
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
155
Pax fatalities:
Other fatalities:
Total fatalities:
129
Captain / Total flying hours:
6497
Captain / Total hours on type:
6287.00
Copilot / Total flying hours:
5295
Copilot / Total hours on type:
1215
Aircraft flight hours:
39541
Aircraft flight cycles:
14308
Circumstances:
On April 15, 2002, about 11:21:17, Air China flight 129, a Boeing 767-200ER, operated by Air China International (Air China hereinafter), en route from Beijing, China to Busan, Korea, crashed during a circling approach, on Mt. Dotdae located 4.6 km north of runway 18R threshold at Busan/Gimhae International Airport (Gimhae airport hereinafter), at an elevation of 204 meters. The flight was a regularly scheduled international passenger service flight operating under instrument flight rules (IFR) within Korean airspace, according to the provisions of the Korean Aviation Act and Convention on International Civil Aviation. One captain, one first officer and one second officer, eight flight attendants, and 155 passengers were on board at the time of the accident. The aircraft was completely destroyed by impact forces and a post crash fire. Of the 166 persons on board, 37 persons including the captain and two flight attendants survived, while the remaining 129 occupants including two copilots were killed.
Probable cause:
3.1 Findings Related to Probable Causes:
1. The flight crew of flight 129 performed the circling approach, not being aware of the weather minima of widebody aircraft (B767-200) for landing, and in the approach briefing, did not include the missed approach, etc., among the items specified in Air China’s operations and training manuals.
2. The flight crew exercised poor crew resource management and lost situational awareness during the circling approach to runway 18R, which led them to fly outside of the circling approach area, delaying the base turn, contrary to the captain’s intention to make a timely base turn.
3. The flight crew did not execute a missed approach when they lost sight of the runway during the circling approach to runway 18R, which led them to strike high terrain (mountain) near the airport.
4. When the first officer advised the captain to execute a missed approach about 5 seconds before impact, the captain did not react, nor did the first officer initiate the missed approach himself.
Final Report:

Crash of a GAF Nomad N.24A in Weston-on-the-Green

Date & Time: Apr 13, 2002 at 0830 LT
Type of aircraft:
Registration:
OY-JRW
Flight Phase:
Survivors:
Yes
Schedule:
Weston-on-the-Green - Weston-on-the-Green
MSN:
117
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
581
Captain / Total hours on type:
51.00
Circumstances:
A series of parachute flights had been planned from Weston-on-the-Green. The forecast conditions were good, predicting a surface wind of 360°/10 kt, visibility 30 km, with no significant weather and some strato-cumulus cloud with a base of 3,000 feet. The first flight, which consumed 144 lb of fuel, was completed successfully with 12 parachutists jumping from 12,000 feet. Thirteen parachutists boarded for the second flight and the aircraft was cleared to take off from the dry surface of grass Runway 01 (take off run available 3,194 feet). The surface wind at the time was 360°/15 kt with no significant weather and the temperature was 15°C. The pilot subsequently reported that he checked the condition levers were set to 100% N2, the flaps were set to 10° and that the trim was set in the take off range. He also reported that the company recommended power of 738°C turbine outlet temperature (TOT), and 89 pounds per square inch (psi) manifold pressure were set and achieved during the take off run. This power setting was equivalent to the 'Max Cruise Rating' as specified in the 'Operating Limits' section of the aircraft manual and no take off performance charts or data concerning 'take off distance required' (TODR) and 'accelerate stop distance required' (ASDR) information was available. The maximum take off power available (5 minute limit) was 810°C TOT and 102 psi. At approximately 80 to 83 kt (scheduled rotation speed 71 kt) the pilot pulled back on the control column. He reported that, 'the aircraft felt more nose heavy', 'the aircraft nose did not rise and he perceived that the aircraft was no longer accelerating'. He decided to abort the take off, commenced braking and set the condition levers to the full reverse position. As the aircraft decelerated he turned it to the right in order to avoid trees and bushes ahead. The aircraft struck a small earth mound, whilst still travelling at about 15-20 kt, and came to an abrupt halt. The pilot shut down both engines and selected the fuel and the battery to OFF. The crew and passengers evacuated the aircraft unaided.
Probable cause:
The pilot had successfully completed a similar flight in the same aircraft, in benign meteorological conditions and the available evidence suggests that the aircraft was serviceable. He reported that during the second take off run 'the company recommended take off power of 738°C TOT and 89 psi was set and achieved'. The take off was therefore attempted with only 89 -90% of the maximum power available. This would have had the effect of not only increasing the take off distance but also the 'ASDR' to achieve a successful rejected take off from a speed at or beyond normal rotate speed. With the flap position and trim set correctly for take off the pilot attempted to rotate the aircraft between 80 to 83 kt, at least 9 kt above the scheduled rotation speed of 71 kt. If the aircraft loading had been within the limits of mass and CG prompt rotation of the aircraft should have occurred. This however did not happen and instead the pilot felt the aircraft to be 'more nose heavy than normal'. The exact mass and CG for this flight are uncertain. If the CG position was at the forward limit for the calculated mass, control column forces would have been high but not sufficiently high to prevent a successful takeoff. Extreme forces would only have been encountered if the aircraft CG position was significantly in error. It is therefore considered that for the second takeoff of the day the aircraft CG was significantly forward of the forward CG limit.
Final Report:

Crash of a Swearingen SA227AC Metro III in Palma de Majorca: 2 killed

Date & Time: Apr 12, 2002 at 0506 LT
Type of aircraft:
Operator:
Registration:
EC-GKR
Flight Type:
Survivors:
No
Schedule:
Madrid - Palma de Mallorca
MSN:
AC-620
YOM:
1985
Flight number:
TDC306
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3897
Captain / Total hours on type:
2162.00
Copilot / Total flying hours:
697
Copilot / Total hours on type:
487
Aircraft flight hours:
29726
Circumstances:
The twin engine aircraft departed Madrid-Barajas Airport at 0338LT on a cargo flight to Palma de Mallorca, carrying two pilots and a load of 1,340 kilos consisting of various goods. On a night approach to Palm Airport runway 24L, the crew completed a last turn when the aircraft stalled and struck the runway surface. Out of control, it veered to the right, collided with a lightning system and came to rest upside down in a grassy area. The aircraft was destroyed and both pilots were killed.
Probable cause:
The accident is considered to have occurred as a result of the aircraft performing a very close turn maneuver performed at night, at low altitude and descending in a non-standard approach, not in accordance with normal procedures and company procedures. The crew could not control the descending aircraft due to a possible start of loss of lift, slip on the turn, or both.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Brescia

Date & Time: Apr 12, 2002
Type of aircraft:
Operator:
Registration:
I-SASA
Flight Phase:
Survivors:
Yes
MSN:
31-8004021
YOM:
1980
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed upon takeoff for unknown reasons. There were no casualties.