Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Bugalaga

Date & Time: Jan 18, 2002 at 1000 LT
Operator:
Registration:
PK-YPC
Flight Type:
Survivors:
Yes
Schedule:
Nabire - Bugalaga
MSN:
726
YOM:
1971
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
8500
Circumstances:
Upon landing on runway 06, the single engine aircraft bounced twice then veered off runway and came to rest in bushes. Both pilots escaped unhurt while the aircraft was damaged beyond repair.
Probable cause:
The crew completed the landing roll with a tailwind component and the runway was in poor conditions at the time of the accident, which remained a contributing factor.

Crash of a Boeing 737-3Q8 in Yogyakarta: 1 killed

Date & Time: Jan 16, 2002 at 1200 LT
Type of aircraft:
Operator:
Registration:
PK-GWA
Survivors:
Yes
Schedule:
Mataram-Jogjakarta
MSN:
24403
YOM:
1989
Flight number:
GA421
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
54
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
27701
Aircraft flight cycles:
24139
Circumstances:
On January 16, 2002, at approximately 09:24 UTC, a Boeing 737-300, PK-GWA, ditched into the waters of the Bengawan Solo River, Central Java during a forced landing, following loss of power on both engines as the aircraft was descending through 19,000 ft. The dual engine flame out occurred shortly after the aircraft entered severe cumulonimbus cloud formations with turbulence and heavy rain and ice. The aircraft, owned and operated by PT Garuda Indonesia as Flight GA 421, had departed Ampenan at 08:32 UTC, on a regular scheduled commercial flight with destination Yogyakarta. At departure VMC conditions prevailed. The flight from Ampenan was reported uneventful until its arrival in the Yogyakarta area. The crew stated that they observed cumulonimbus cloud formations on their weather radar. The aircraft descended from cruise altitude of 31,000 ft to 28,000ft as instructed by BALI ATC at 09.08 UTC due to traffic on eastbound at FL290. As they began their descent from FL 280 at 09.13 UTC, prior to entering the clouds at 23,000 feet, the crew noted at the radar screen red cells with two green and yellow areas to the left and right of their intended flight path. The Pilot Flying decided to take the left opening above PURWO NDB. The flight crew prepared to enter turbulence by setting turbulence speed at 280 knots, seatbelt on, engine ignitions on FLT and anti-ice on. Then the Pilot Flying requested to BALI ATC to descend to FL 190 and was cleared by Semarang APP at 09.13 UTC. Shortly after the aircraft entered the area covered by Cumulonimbus cells, the crew noted severe turbulence and heavy precipitation. According to the flight crew interview, the crew noted aircraft electrical power generators loss and they were only having primary engine instrument indications and captain flight instruments, which finally identified both engines flame-out. While in the precipitation, the flight crew attempted at least two engine relights, and one attempt of APU start. As the APU start was initiated, the crew noted total electrical loss of the aircraft. The aircraft descended into VMC conditions at about 8,000 ft altitude. The PIC spotted the Bengawan Solo River and decided to land the aircraft on the river. The crew announced to the flight attendant to prepare emergency landing procedure. The aircraft landed successfully between two iron bridges in the upstream direction, and came to a stop with its nose pointing to the right of the landing path. The aircraft settled down on its belly, with the wings and control surfaces largely intact, and was partially submerged. The evacuation following the landing was successful. Twelve passengers suffered injuries, the flight crew and two flight attendants were uninjured, one flight attendant suffered serious injuries, and another flight attendant was found in the waters of the river and fatally injured.
Probable cause:
The NTSC determines that the probable causes of the accident were the combination of:
1) The aircraft had entered severe hail and rain during weather avoidance which subsequently caused both engines flame out;
2) Two attempts of engine-relight failed because the aircraft was still in the precipitation beyond the engines’ certified capabilities; and
3) During the second attempt relight, the aircraft suffered run-out electrical power.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Chilpancingo: 4 killed

Date & Time: Jan 15, 2002 at 0845 LT
Operator:
Registration:
XC-FIT
Flight Type:
Survivors:
Yes
Schedule:
Mexico City – Chilpancingo
MSN:
752
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After touchdown on runway 15 at Chilpancingo-Doctor Alfonso G. Alarcón Airport, the aircraft went out of control, veered off runway to the right, struck several earth mounds and eventually collided with a concrete wall, coming to rest upside down. Four passengers were killed and 14 other occupants were injured. It was reported that the aircraft' speed was excessive at touchdown.

Crash of a Boeing 737-291 in Pekanbaru

Date & Time: Jan 14, 2002 at 1015 LT
Type of aircraft:
Operator:
Registration:
PK-LID
Flight Phase:
Survivors:
Yes
Schedule:
Pekanbaru - Batam
MSN:
20363
YOM:
1969
Flight number:
JT386
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
96
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17266
Copilot / Total flying hours:
3700
Copilot / Total hours on type:
2500
Aircraft flight hours:
68133
Aircraft flight cycles:
66998
Circumstances:
The flight was a second route of four routes on a first day of two days schedule flight for the crew. All crew have flight schedule on the previous day and returned to Jakarta. The first flight was from Jakarta to Pekanbaru with departure schedule on 08.00 LT (01.00 UTC). All crew did the pre-flight check completely but did not check the audio warning and departed Jakarta on schedule. The flight was normal and landed in Pekanbaru on schedule. There was no problem reported. Transit in Pekanbaru for about 30 minutes and the flight was ready to continue the next flight to Batam. At 10.15 LT (03.05) the boarding process has been completed and all flight documents have ready. First Officer asked for start clearance and received weather information in Syarif Kasim Airport. The weather was fine, wind calm and clear. After start completed, the aircraft taxi to the beginning of runway 18. Flight crews have set the V1, VR, V2 and V2+15 speed bugs according to the load sheet. Take off power decide to use “reduced take off power” with assumed temperature 35o C while the actual temperature was 27° C. flight Attendant have completed the passenger briefing includes rearrange seat for the seats near the “over wing exit windows”. The checklist was done, but flight crews were not sure the indication of flap setting. When ready for take off, flight crew gave a warning to the flight attendants to take their seats. First Officer acted as “Pilot Flying”. PIC opened the power and adjusted to the required take off power setting. The aircraft rolled normal and there was no abnormal indication. PIC called “V1” and “ROTATE” at speed bugs value setting, and the First Officer rotated the control column and set to 150 ANU (Aircraft Nose Up) pitch. The aircraft’s nose was lifted up but the aircraft did not airborne. Flight attendant who was sitting at the rear felt that the nose was higher than normal. Officer also felt stick shaker, warning for approaching stall. First Officer suddenly noticed a warning light illuminated and cross-checked. He found than the warning came from the problem on the air conditioning system. Both pilots also felt pain in the ear. Recognizing this situation, PIC decided to continue the take off and called to the First Officer “disregard”. Realized that the aircraft did not airborne PIC added the power by moving power levers forward. The speed was increasing and passed the speed bug setting for V2+15 ( ± 158 KIAS) but the aircraft did not get airborne. PIC noticed that the runway end getting closer and he thought that the aircraft would not airborne, he decided to abort the take off and called “STOP”. PIC retarded the power levers to idle and set to reverse thrust, extended the speed brake and applied brake. Nose of the aircraft went down hard and made the front left door (L1) opened and 2 trolleys at front galley move forward and blocked the cockpit door. Flight crew turns the aircraft slightly to the right to avoid approach lights ahead. The aircraft moved out or the runway to the right side of the approach lights. After hit some trees the aircraft stopped at ± 275 meters from the end of runway on heading 285°. One passenger had serious injury and the rest had minor injury, all crew were safe and not injured. No one killed in this accident, while the aircraft considered total loss.
Probable cause:
Findings:
1. The flight crews have proper qualification to fly the aircraft.
2. The aircraft did not exceed its Maximum Take-Off Weight limitation specified in the AOM.
3. Cockpit area microphone did not function at the time of the accident. Therefore, the only sounds/conversations recorded were only when there were radio transmissions.
4. FDR data show that the engines operated normally.
5. FDR data show similar trajectory with an aircraft of the type and loading condition tried to take-off with zero flap.
6. The aircraft flap system was found to function normally. Therefore, should the flap selector moved to non-zero position, the flap should move to the selected position.
7. The crew did not perform Before Take-off Checklist as stated in the Boeing 737-200 Pilot’s Handbook, Chapter Normal Operating Procedures.
8. The aural warning system, except its circuit breaker, function normally. Therefore, the cause of the absence of take-off warning is the wear out latch on the CB that caused it to open.
9. The food trolley safety lock and food trolley safety strap on the front galley did not function properly that the trolley loose upon impact and blocking the cockpit door.
10. The escape slides fail to deploy. All the slides have no expiration date or marked last inspection date-as regulated in CASR 121.309.
11. Shear pins on the engines mounting function properly to separate the engine from the wing and therefore minimize the risk of fire in the accident.
Final Remarks:
Since there is no indication that flaps system failure or flap asymmetry contributes in the failure of flap to travel to take-off configuration, the most probable cause for the failure is the improper execution of take-off checklist. Failure of the maintenance to identify the real problem on the aural warning CB, causes the CB to open during the accident and therefore is a contributing factor to the accident.
Final Report:

Crash of a Canadair CL-604 Challenger in Birmingham: 5 killed

Date & Time: Jan 4, 2002 at 1207 LT
Type of aircraft:
Operator:
Registration:
N90AG
Flight Phase:
Survivors:
No
Schedule:
Birmingham - Bangor - Duluth
MSN:
5414
YOM:
1999
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10000
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
20000
Copilot / Total hours on type:
800
Aircraft flight hours:
1594
Aircraft flight cycles:
797
Circumstances:
Following ATC clearance, engine start was at 1156 hrs and N90AG was cleared to taxi at 1201 hrs. All radio calls during the accident flight were made by the commander, seated in the right cockpit seat. During taxi, the crew completed their normal Before Takeoff Checks; these included confirmation that the control checks had been completed and that anti-ice might be required immediately after takeoff. Flap 20 had been selected for takeoff and the following speeds had been calculated and briefed by the pilots: V1 137 kt; VR 140 kt; V2 147 kt. By 1206 hrs, the aircraft was cleared to line up on Runway 15. At 1207 hrs, N90AG was cleared for takeoff with a surface wind of 140°/8 kt. The pilot in the left seat was handling the controls. Takeoff appeared normal up to lift-off. Rotation was started at about 146 kt with the elevator position being increased to 8°, in the aircraft nose up sense, resulting in an initial pitch rate of around 4°/second. Lift-off occurred 2 seconds later, at about 153 kt and with a pitch attitude of about 8° nose-up. Once airborne, the elevator position was reduced to 3° aircraft nose-up whilst the pitch rate increased to about 5°/second. Immediately after lift-off, the aircraft started to bank to the left. The rate of bank increased rapidly and 2 seconds after lift-off the bank angle had reached 50°. At that point, the aircraft heading had diverged about 10° to the left. Opposite aileron, followed closely by right rudder, was applied as the aircraft started banking; full right aileron and full right rudder had been applied within 1 second and were maintained until the end of the recording. As the bank angle continued to increase, progressively more aircraft nose-up elevator was applied. Stick-shaker operation initiated 3.5 seconds after lift-off and the recorders ceased 2 seconds later. The aircraft struck the ground, inverted, adjacent to the runway. The last recorded aircraft attitude was approximately 111° left bank and 13° nose-down pitch; the final recorded heading was about 114° (M). The aircraft was destroyed by impact forces and a post crash fire and all five occupants were killed, among them John Shumejda, President of the Massey-Ferguson Group and Ed Swingle, Vice President. The aircraft was leased by AGCO Massey-Ferguson.
Probable cause:
Causal factors:
1. The crew did not ensure that N90AG’s wings were clear of frost prior to takeoff.
2. Reduction of the wing stall angle of attack, due to the surface roughness associated with frost contamination, to below that at which the stall protection system was effective.
3. Possible impairment of crew performance by the combined effects of a non-prescription drug, jet-lag and fatigue.
Final Report:

Crash of a Beechcraft C90 King Air in Cradock

Date & Time: Dec 23, 2001 at 1630 LT
Type of aircraft:
Operator:
Registration:
ZS-INN
Flight Type:
Survivors:
Yes
Schedule:
Port Elizabeth - Cradock
MSN:
LJ-523
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3599
Captain / Total hours on type:
118.00
Circumstances:
The private pilot was accompanied by his wife and his two daughters on a flight from Port Elizabeth to his farm in the Cradock district. On arrival at Cradock, the pilot apparently over-flew the runway for inspection and was on the downwind leg when the aircraft started to roll and yaw to the left. All engine indications were normal and the pilot had to decrease power on the right-hand engine in order to maintain control of the aircraft. With the reduction in power of the right-hand engine, the pilot was unable to maintain height and executed a forced landing on an open field. The aircraft was extensively damaged during the forced landing but no injuries were sustained. An on-site investigation was carried out on 24 December 2000 after which the aircraft was recovered to Lanseria aerodrome for further inspection. On inspection of the Left-hand propeller it was noted that the carbon block of the low pitch proximity sensor, which normally runs inside the Low-Pitch stop collar, was bent down at an angle, which would have rendered the secondary Low-Pitch stop inoperative. Due to the fact that the aircraft sustained damage to it's electronic circuitry it was not possible to verify the proper operation of the propeller pitch control system.
Probable cause:
Due to damage sustained during the accident, the proper operation of the propeller pitch control system could not be verified. The cause of the accident therefore remains undetermined.

Crash of a Cessna 560 Citation V in Zurich: 2 killed

Date & Time: Dec 20, 2001 at 2206 LT
Type of aircraft:
Operator:
Registration:
HB-VLV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Bern
MSN:
560-0077
YOM:
1990
Flight number:
EAB220
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4761
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
1110
Copilot / Total hours on type:
401
Aircraft flight hours:
3559
Aircraft flight cycles:
3528
Circumstances:
At 19:43:49 UTC the crew of EAB 220 called clearance delivery (CLD) for the first time and asked if their flight plan to Bern-Belp was available. The answer was in the affirmative and the CLD air traffic controller informed the crew that they would need authorisation for the landing in Bern-Belp. Once it had been clarified that this authorisation had been obtained, EAB 220 called back a little later. CLD informed the pilots that their departure was planned from runway 34. However, they would have to expect a delay at that time, as arrivals and departures were being handled in batches. EAB 220 was scheduled in the next batch for take-off. CLD intimated to the crew an approximate departure time of 20:30 UTC. When the crew called back at 20:13:49 UTC to ask for any news, CLD informed them that departure would now take place in about 45 minutes. Since visual conditions were deteriorating due to the thickening fog, air traffic control had to increase the separation between arriving aircraft. As a result, flight EAB 220’s estimated departure time was delayed to about 21:00 UTC. At 20:24:38 UTC CLD transmitted to the crew a departure clearance. Flight EAB 220 was assigned the standard instrument departure (SID) “WILLISAU 3N” and transponder code 1403. In addition, a departure time of 21:07 UTC was estimated. The CEO of Eagle Air Ltd. had applied in Bern-Belp for a special authorisation for a late landing after 21:00 UTC and obtained a slot until 21:30 UTC at the latest. Since the departure of HB-VLV in Zurich was being further and further delayed, the crew found themselves under increasing time pressure. The crew were in contact with the CEO several times; at the time, the latter was performing the function of the dispatcher. In order to ensure the arrival of HB-VLV in Bern-Belp by 21:30 UTC at the latest, he also telephoned the duty manager in Zurich control tower and urged him several times for an earlier departure time. After a frequency change to apron control, the apron controller cleared EAB 220 to start its engines at 20:43:50 UTC. Approximately at the same time, an airport manager observed that HB-VLV’s right-hand engine was running, although only one pilot was present in the cockpit. He was sitting in the right-hand seat. The other crew member, probably the commander, was using a scraper to remove ice deposits from the left wing. The eye witness later observed how this crew member occupied the left-hand position in the cockpit, shortly before taxiing. Since the pilots were eager to leave their stand in the General Aviation Centre (GAC) Sector 1 as quickly as possible, they were cleared to taxi as far as the holding point for runway 28 just 2 minutes later. There they had to wait for a taxiing Saab 2000 to pass in the opposite direction. EAB 220 was then instructed by the apron controller to continue taxiing to the holding point for runway 34 via taxiways ALPHA, INNER and ECHO. One minute after taxi clearance had been given, the crew of EAB 220 again asked for the wording of this clearance: “Swiss Eagle 220, sorry for that, can you say the clearance again?” It must remain open whether HB-VLV had missed the intersection in the direction of the INNER taxiway. It is clear, however, that the apron controller had to intervene shortly afterwards with a correction: “220, continue on taxiway INNER, INNER, and then ECHO to Holding Point 34, Echo 9”. At 20:56:50 UTC flight EAB 220 made contact with Aerodrome Control (ADC) and stated that the aircraft was on Echo 9 just before the start of runway 34. The air traffic controller (ATCO) requested the crew to wait short of runway 34, since approaches were still taking place in the opposite direction on runway 16. At 21:04:51 UTC ADC cleared the aircraft to line up on runway 34. The crew taxied onto runway 34 and – after they had received take-off clearance at 21:05:54 UTC – initiated a rolling take-off by setting take-off power. At this time, meteorological visibility was 100 m with partial fog. Since the left-hand engine was run up within six seconds to 102 percent of take-off power and the right-hand engine to 58 percent, for a few seconds during the acceleration phase the aircraft veered on the runway to such an extent that it’s heading changed 10 degrees to the right. The crew were only able to bring the aircraft back into alignment with the runway by making a major nose-wheel control correction and by distinctly reducing the thrust of the left-hand engine. Afterwards the two engines were brought synchronously to take-off power and the take-off continued. Flight EAB 220 lifted off from runway 34 at 21:06:40 UTC. Shortly after take-off, the commander of EAB 220 acknowledged the request to change frequency to departure control. At about the same time various members of the airport fire-fighting services, who were inside and in front of the fire-fighting unit satellite “North” between runways 34 and 32, heard noises and saw visual indications of a low-flying aircraft. Immediately afterwards the noise of a crash and the flash of a fire were noted. At 21:07 UTC the aircraft impacted onto the frozen ground 400 m to the south-east of the end of runway 34 and skidded in a northerly direction, leaving a trail of debris. The main body of the wreck finally came to rest 500 m beyond the site of initial impact on runway 14/32. The rescue services reached the burning wreck after a few minutes. DFDR data revealed that the autopilot was disengaged during the whole flight.
Probable cause:
The accident is attributable to the fact that the crew of HB-VLV did not continue their climb after take-off. As a result the aircraft came in a descent and collided with the terrain.
The investigation determined the following causal factor for the accident:
• With a high degree of probability the crew lost spatial orientation after take-off, leading to an unintentional loss of altitude.
The following factors contributed to the accident:
• The copilot’s basic training in instrument flying did not include night instrument take-offs.
• The crew’s method of working was adversely affected by great time pressure.
• Executing the take-off as a rolling take-off was not adapted to the prevailing meteorological conditions.
• There was no system in the aircraft which triggers an alarm in the event of a loss of altitude after take-off (GPWS).
• The instrumentation on the copilot’s side of the aircraft involved in the accident was not optimal.
Final Report:

Crash of a Lockheed C-130 Hercules in Lhokseumawe

Date & Time: Dec 20, 2001 at 0935 LT
Type of aircraft:
Operator:
Registration:
A-1329
Flight Type:
Survivors:
Yes
Schedule:
Jakarta - Lhokseumawe
MSN:
4824
YOM:
1979
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Lhokseumawe-Malikussaleh Airport, the four engine aircraft went out of control, veered off runway and came to rest in a marshy area, bursting into flames. All 95 occupants were rescued, among them seven passengers were injured. The aircraft was destroyed by a post crash fire.

Crash of a Piper PA-46-350P Malibu Mirage in Raleigh: 3 killed

Date & Time: Dec 12, 2001 at 1904 LT
Operator:
Registration:
N41003
Survivors:
No
Schedule:
Dothan - Raleigh
MSN:
46-22044
YOM:
1989
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
926
Captain / Total hours on type:
10.00
Aircraft flight hours:
1679
Circumstances:
The flight was cleared for the ILS approach to runway 5R. The flight was at mid runway, at 2,100 feet, heading 049 degrees, at a speed of 163 knots, when the pilot stated "...missed approach." He was instructed to maintain 2,000, and to fly runway heading. Radar showed N41003 started a right turn, was flying away from the airport/VOR, descending. At a point 0.57 miles from the airport/VOR, the flight had descended to 1,500 feet, was turning right, and increasing speed. The flight had descended 400 feet, and had traveled about 0.32 miles in 10 seconds. When radio and radar contact were lost, the flight was 2.35 miles from the airport/VOR, level at 1,600 feet, on a heading of 123 degrees, and at a speed of 169 knots. The published decision height (DH) was 620 feet mean sea level (msl). The published minimum visibility was 1/2 mile. The published Missed Approach in use at the time of the accident was; "Climb to 1,000 [feet], then climbing right turn to 2,500 [feet] via heading 130 degrees, and RDU R-087 [087 degree radial] to ZEBUL Int [intersection] and hold." A witness stated that the aircraft was flying low, power seemed to be in a cruise configuration, and maintaining the same sound up until the crash. The reported weather at the time was: Winds 050 at 5 knots, visibility 1/2 statute mile, obscuration fog and drizzle, ceiling overcast 100, temperature and dew point 11 C, altimeter 30.30 in HG. At the time of the accident the pilot had 10 total flight hours in this make and model airplane; 33 total night flight hours; and 59 total instrument flight hours.
Probable cause:
The pilot's failure to maintain control of the airplane, due to spatial disorientation, while performing a missed approach, resulting in an uncontrolled descent, and subsequent impact with a tree and a house. Factors in this accident were dark night, fog, drizzle, the pilot's lack of total instrument time, and his lack of total experience in this type of aircraft.
Final Report:

Crash of an Antonov AN-32 in Luzamba

Date & Time: Dec 11, 2001
Type of aircraft:
Operator:
Registration:
D2-FEO
Flight Type:
Survivors:
Yes
Schedule:
Luanda - Luzamba
MSN:
18 10
YOM:
1989
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Luzamba Airport, the aircraft was unable to stop within the remaining distance, overran and came to a halt. All six occupants escaped uninjured while the aircraft was damaged beyond repair.