Airport (less than 10 km from airport)

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Embraer EMB-505 Phenom 300

Schedule:

Thiruvananthapuram - Dubai

MSN:

32700/434

YOM:

2003

Flight number:

EK521

Location:

Dubai

Country:

United Arab Emirates

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

282

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

7457

Captain / Total hours on type:

5123.00

Copilot / Total flying hours:

7957

Copilot / Total hours on type:

1292

Aircraft flight hours:

58169

Aircraft flight cycles:

13620

Circumstances:

On 3 August 2016, an Emirates Boeing 777-31H Aircraft, registration A6-EMW, operating a scheduled passenger flight UAE521, departed Trivandrum International Airport (VOTV), India, at 0506 UTC for a 3 hour 30 minute flight to Dubai International Airport (OMDB), the United Arab Emirates, with 282 passengers, 2 flight crew and 16 cabin crew members on board. The Commander attempted to perform a tailwind manual landing during an automatic terminal information service (ATIS) forecasted moderate windshear warning affecting all runways at OMDB. The tailwind was within the operational limitations of the Aircraft. During the landing on runway 12L at OMDB the Commander, who was the pilot flying, decided to fly a go-around, as he was unable to land the Aircraft within the runway touchdown zone. The go-around decision was based on the perception that the Aircraft would not land due to thermals and not due to a windshear encounter. For this reason, the Commander elected to fly a normal go-around and not the windshear escape maneuver. The flight crew initiated the flight crew operations manual (FCOM) Go-around and Missed Approach Procedure and the Commander pushed the TO/GA switch. As designed, because the Aircraft had touched down, the TO/GA switches became inhibited and had no effect on the autothrottle (A/T). The flight crew stated that they were not aware of the touchdown that lasted for six seconds. After becoming airborne during the go-around attempt, the Aircraft climbed to a height of 85 ft radio altitude above the runway surface. The flight crew did not observe that both thrust levers had remained at the idle position and that the engine thrust remained at idle. The Aircraft quickly sank towards the runway as the airspeed was insufficient to support the climb. As the Aircraft lost height and speed, the Commander initiated the windshear escape maneuver procedure and rapidly advanced both thrust levers. This action was too late to avoid the impact with runway 12L. Eighteen seconds after the initiation of the go-around the Aircraft impacted the runway at 0837:38 UTC and slid on its lower fuselage along the runway surface for approximately 32 seconds covering a distance of approximately 800 meters before coming to rest adjacent to taxiway Mike 13. The Aircraft remained intact during its movement along the runway protecting the occupants however, several fuselage mounted components and the No.2 engine/pylon assembly separated from the Aircraft. During the evacuation, several passenger door escape slides became unusable. Many passengers evacuated the Aircraft taking their carry-on baggage with them. Except for the Commander and the senior cabin crew member who evacuated after the center wing tank explosion, all of the other occupants evacuated via the operational escape slides in approximately 6 minutes and 40 seconds. Twenty-one passengers, one flight crewmember, and six cabin crew members sustained minor injuries. Four cabin crew members sustained serious injuries. Approximately 9 minutes and 40 seconds after the Aircraft came to rest, the center wing tank exploded which caused a large section of the right wing upper skin to be liberated. As the panel fell to the ground, it struck and fatally injured a firefighter. The Aircraft was eventually destroyed due to the subsequent fire. Following the Accident, the Operator (Emirates), the General Civil Aviation Authority (GCAA), Dubai Airports and Dubai Air Navigation Services (‘dans’) implemented several safety actions. In this Final Report, the AAIS issues safety recommendations addressed to the Operator, the GCAA, The Boeing Company, the Federal Aviation Administration (FAA), Dubai Airports, ‘dans’, and the International Civil Aviation Organization (ICAO).

Probable cause:

The Air Accident Investigation Sector determines that the causes of the Accident are:
(a) During the attempted go-around, except for the last three seconds prior to impact, both engine thrust levers, and therefore engine thrust, remained at idle. Consequently, the Aircraft’s energy state was insufficient to sustain flight.
(b) The flight crew did not effectively scan and monitor the primary flight instrumentation parameters during the landing and the attempted go-around.
(c) The flight crew were unaware that the autothrottle (A/T) had not responded to move the engine thrust levers to the TO/GA position after the Commander pushed the TO/GA switch at the initiation of the FCOM Go-around and Missed Approach Procedure.
(d) The flight crew did not take corrective action to increase engine thrust because they omitted the engine thrust verification steps of the FCOM Go-around and Missed Approach Procedure.
The Investigation determines that the following were contributory factors to the Accident:
(a) The flight crew were unable to land the Aircraft within the touchdown zone during the attempted tailwind landing because of an early flare initiation, and increased airspeed due to a shift in wind direction, which took place approximately 650 m beyond the runway threshold.
(b) When the Commander decided to fly a go-around, his perception was that the Aircraft was still airborne. In pushing the TO/GA switch, he expected that the autothrottle (A/T) would respond and automatically manage the engine thrust during the go-around.
(c) Based on the flight crew’s inaccurate situation awareness of the Aircraft state, and situational stress related to the increased workload involved in flying the go-around maneuver, they were unaware that the Aircraft’s main gear had touched down which caused the TO/GA switches to become inhibited. Additionally, the flight crew were unaware that the A/T mode had remained at ‘IDLE’ after the TO/GA switch was pushed.
(d) The flight crew reliance on automation and lack of training in flying go-arounds from close to the runway surface and with the TO/GA switches inhibited, significantly affected the flight crew performance in a critical flight situation which was different to that experienced by them during their simulated training flights.
(e) The flight crew did not monitor the flight mode annunciations (FMA) changes after the TO/GA switch was pushed because:
1. According to the Operator’s procedure, as per FCOM Flight Mode Annunciations (FMA), FMA changes are not required to be announced for landing when the aircraft is below 200 ft;
2. Callouts of FMA changes were not included in the Operator’s FCOM Go-Around and Missed Approach Procedures.
3. Callouts of FMA changes were not included in the Operator’s FCTM Go-Around and Missed Approach training.
(f) The Operator’s OM-A policy required the use of the A/T for engine thrust management for all phases of flight. This policy did not consider pilot actions that would be necessary during a go-around initiated while the A/T was armed and active and the TO/GA switches were inhibited.
(g) The FCOM Go-Around and Missed Approach Procedure did not contain steps for verbal verification callouts of engine thrust state.
(h) The Aircraft systems, as designed, did not alert the flight crew that the TO/GA switches were inhibited at the time when the Commander pushed the TO/GA switch with the A/T armed and active.
(i) The Aircraft systems, as designed, did not alert the flight crew to the inconsistency between the Aircraft configuration and the thrust setting necessary to perform a successful go-around.
(j) Air traffic control did not pass essential information about windshear reported by a preceding landing flight crew and that two flights performed go-arounds after passing over the runway threshold. The flight crew decision-making process, during the approach and landing, was deprived of this critical information.
(k) The modification of the go-around procedure by air traffic control four seconds after the Aircraft became airborne coincided with the landing gear selection to the ‘up’ position. This added to the flight crew workload as they attentively listened and the Copilot responded to the air traffic control instruction which required a change of missed approach altitude from 3,000 ft to 4,000 ft to be set. The flight crews’ concentration on their primary task of flying the Aircraft and monitoring was momentarily affected as both the FMA verification and the flight director status were missed.

Final Report:

Crash of an Embraer EMB-505 Phenom 300 in Houston

Date & Time: Jul 26, 2016 at 1510 LT

Type of aircraft:

Operator:

Registration:

N362FX

Flight Phase:

Charter/Taxi (Non Scheduled Revenue Flight)

Flight Type:

Survivors:

Site:

Beechcraft 200 Super King Air

Schedule:

Scottsdale - Houston

MSN:

500-00239

YOM:

2014

Flight number:

LXJ362

Location:

Houston-Sugar Land

Texas

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

9246

Captain / Total hours on type:

1358.00

Copilot / Total flying hours:

11362

Copilot / Total hours on type:

962

Aircraft flight hours:

1880

Circumstances:

The pilot executed an instrument approach and landing in heavy rain. The airplane touched down about 21 knots above the applicable landing reference speed, which was consistent with an unstabilized approach. The airplane touched down near the displaced runway threshold about 128 kts, and both wing ground spoilers automatically deployed. The pilot reported that the airplane touched down “solidly,” and he started braking promptly, but the airplane did not slow down. The main wheels initially spun up; however, both wheel speeds subsequently decayed consistent with hydroplaning in the heavy rain conditions. When the wheel speeds did not recover, the brake control unit advised the flight crew of an anti-skid failure; the pilot recalled an anti-skid CAS message displayed at some point during the landing. The pilot subsequently activated the emergency brake system and the wheel speeds decayed. The airplane ultimately overran the departure end of the runway about 60 kts, crossed an airport perimeter road, and encountered a small creek before coming to rest. The wings had separated from, and were located immediately adjacent to, the fuselage. The pilot reported light to moderate rain began on final approach. Weather data and surveillance images indicated that heavy rain and limited visibility prevailed at the airport during the landing. Thunderstorms were active in the vicinity and the rainfall rate at the time of the accident landing was between 4.2 and 6.0 inches per hour. About 4 minutes before the accident, a surface observation recorded the visibility as 3 miles. However, 3 minutes later, the observed visibility had decreased to 3/8 mile. A review of the available information indicated that the tower controller advised the pilot of changing wind conditions and of better weather west of the airport but did not update the pilot regarding visibility along the final approach course or precipitation at the airport. The pilot stated that the rain started 2 to 3 minutes before he landed and commented that it was not the heaviest rain that he had ever landed in. The pilot was using the multifunction display and a tablet for weather radar, which showed green and yellow returns indicating light to moderate rain during the approach. He chose not to turn on the airplane’s onboard weather radar because the other two sources were not indicating severe weather. The runway exhibited skid marks beginning about 1,500 ft from the departure end and each main tire had one patch of reverted rubber wear consistent with reverted rubber hydroplaning. The main landing gear remained extended and both tires remained pressurized. The tire pressures corresponded to a minimum dynamic hydroplaning speed of about 115 kts. The airplane flight manual noted that, in the case of an antiskid failure, the main brakes are to be applied progressively and brake pressure is to be modulated as required. The emergency brake is to be used in the event of a brake failure; however, the pilot activated the emergency brake when the main brakes still functioned; although, without anti-skid protection.

Probable cause:

The airplane’s hydroplaning during the landing roll, which resulted in a runway excursion. Contributing to the accident was the pilot’s continuation of an unstabilized approach, his decision to land in heavy rain conditions, and his improper use of the main and emergency brake systems. Also contributing was the air traffic controller’s failure to disseminate current airport weather conditions to the flight crew in a timely manner.

Final Report:

Crash of a Beechcraft 200 Super King Air in Iqaluit

Date & Time: Jul 17, 2016 at 1217 LT

Type of aircraft:

Operator:

Registration:

C-FCGW

Flight Phase:

Flight Type:

Training

Survivors:

Site:

Cessna 207 Skywagon/Stationair

Schedule:

Iqaluit - Iqaluit

MSN:

BB-207

YOM:

1977

Flight number:

BFF200

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

A Beech 200 Super King Air aircraft operated by Air Nunavut as flight 200, was on a training flight at Iqaluit, NU (CYFB) to upgrade a candidate to captain status. A VFR circuit was executed to simulate a flapless landing. While in the circuit, the crew experienced an actual communication failure on COM 1 while two other aircraft were inbound to Iqaluit. At the end of the downwind leg, a flap failure was simulated and the crew carried out the appropriate checklist. However, the landing checklist was not completed and the aircraft landed with the landing gear in the up position on runway 16. The aircraft skidded on the belly and came to a stop on the runway between taxiway A and G. The crew declared an emergency and evacuated the airplane with no injuries. The aircraft sustained damage to the belly pod and both propellers.

Crash of a Cessna 207A Stationair 8 in Santa Rosa de Yacuma

Date & Time: Jul 16, 2016 at 1600 LT

Type of aircraft:

Operator:

Registration:

CP-2953

Flight Phase:

Flight Type:

Private

Survivors:

Site:

Schedule:

Trinidad – Santa Rosa de Yacuma

MSN:

207-0728

YOM:

1981

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

On approach to Santa Rosa de Yacuma Airport, the pilot encountered poor weather conditions and initiated a go-around as the visibility was poor due to rain falls. Few minutes later, during a second attempt to land, the aircraft passed over the runway threshold when the pilot decided to initiate a second go-around procedure. He made a left turn when he lost control of the airplane that crashed 500 metres past the runway threshold, bursting into flames. The aircraft was destroyed and all six occupants were killed.

Crash of a Lockheed C-130H Hercules at Montijo AFB: 3 killed

Date & Time: Jul 11, 2016 at 1200 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

16804

Flight Phase:

Takeoff (climb)

Flight Type:

Training

Survivors:

Site:

Estremadura - Lisbon District

Schedule:

Montijo AFB - Montijo AFB

MSN:

4777

YOM:

1978

Location:

Montijo AFB

Country:

Portugal

Region:

Europe

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew was completing a local training exercise at Montijo AFB, consisting of touch-and-go maneuvers. During the takeoff roll on runway 26, the four engine aircraft deviated from the centerline to the left then went out of control, veered off runway to the right and eventually crashed 1,460 meters past the runway threshold, bursting into flames. Four crew members were injured while three others were killed. The aircraft was destroyed by a post crash fire.

Crash of a Swearingen SA226T Merlin IIIB in Farmingdale

Date & Time: Jun 20, 2016 at 1758 LT

Type of aircraft:

Swearingen SA226T Merlin III

Operator:

Registration:

N127WD

Flight Phase:

Flight Type:

Training

Survivors:

Site:

Schedule:

White Plains - Farmingdale

MSN:

T-297

YOM:

1978

Location:

Farmingdale-Republic

New York

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

11450

Captain / Total hours on type:

410.00

Copilot / Total flying hours:

1300

Copilot / Total hours on type:

Aircraft flight hours:

4500

Circumstances:

According to the pilot in command (PIC), he was conducting an instructional flight for his "new SIC (second in command)," who was seated in the left seat. He reported that they had flown two previous legs in the retractable landing gear-equipped airplane. He recalled that, during the approach, they discussed the events of their previous flights and had complied with the airport control tower's request to "keep our speed up." During the approach, he called for full flaps and retarded the throttle to flight idle. The PIC asserted that there was no indication that the landing gear was not extended because he did not hear a landing gear warning horn; however, he was wearing a noise-cancelling headset. He added that the landing gear position lights were not visible because the SIC's knee obstructed his view of the lights. He recalled that, following the flare, he heard the propellers hit the runway and that he made the decision not to go around because of unknown damage sustained to the propellers. The airplane touched down and slid to a stop on the runway. The airplane sustained substantial damage to the fuselage bulkheads, longerons, and stringers. The SIC reported that the flight was a training flight in visual flight rules conditions. He noted that the airspace was busy and that, during the approach, he applied full flaps, but they failed to extend the landing gear. He added that he did not hear the landing gear warning horn; however, he was wearing a noise-cancelling headset. The Federal Aviation Administration Aviation Safety Inspector that examined the wreckage reported that, during recovery, the pilot extended the nose landing gear via the normal extension process. However, due to significant damage to the main landing gear (MLG) doors, the MLG was unable to be extended hydraulically or manually. He added that an operational check of the landing gear warning horn was not accomplished because the wreckage was unsafe to enter after it was removed from the runway. The landing gear warning horn was presented by an aural tone in the cockpit and was not configured to be heard through the pilots' noise-cancelling headsets. When asked, the PIC and the SIC both stated that they could not remember who read the airplane flight manual Before Landing checklist.

Probable cause:

The pilot-in-command's failure to extend the landing gear before landing and his failure to use the Before Landing checklist. Contributing to the accident was the pilots' failure to maintain a sterile cockpit during landing.

Final Report:

Crash of a BAe 146-300 in Khark

Date & Time: Jun 19, 2016 at 1335 LT

Type of aircraft:

BAe 146

Operator:

Registration:

EP-MOF

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Ahwaz – Khark

MSN:

E3149

YOM:

1989

Flight number:

IRM4525

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5494

Captain / Total hours on type:

1270.00

Copilot / Total flying hours:

300

Copilot / Total hours on type:

110

Circumstances:

On June 19, 2016, Mahan Air flight IRM 4525 was a scheduled passenger flight which took off from Ahwaz Airport at 1257 LMT (0827 UTC) to destination and landed at Khark Island Airport at 1335 LMT (0905 UTC). After delivery of the flight from BUZ approach to Khark tower, the flight was cleared to land on RWY 31 via visual approach. At 10 NM on final the pilot has asked weather information of the destination so, the captain requested to perform a visual approach for RWY 13. Finally the pilot in command accomplished an un-stabilized approach and landed on the runway after passing long distance of the Runway. Regarding to the length of the runway (7,657 feet) the aircraft overran the end of runway and made runway excursion on runway 13 and came to rest on the unpaved surface after 54 meters past the runway end. The nose landing gear strut has broken and collapsed. The captain instructed the cabin crew to evacuate the aircraft. No unusual occurrences were noticed during departure, en-route and descent.

Probable cause:

The main cause of this accident is wrong behavior of the pilot which descripted as:
- Decision to make a landing on short field RWY 13 with tailwind.
- Un stabilized landing against on normal flight profile
- Weak, obviously, CRM in cockpit.
- Poor judgment and not accomplishing a go around while performing a unstabilized approach.
- Improper calculating of landing speed without focusing on the tailwind component
Contributing factors:
- Anti-skid failures of RH landing gear causing prolong landing distance.
- Instantaneous variable wind condition on aerodrome traffic pattern.
- Late activating of airbrakes and spoilers (especially airbrakes) with tailwind cause to increase the landing roll distance.

Final Report:

Crash of a Piper PA-31-325 Navajo in State College: 2 killed

Date & Time: Jun 16, 2016 at 0830 LT

Type of aircraft:

Piper PA-31-310 Navajo

Operator:

Registration:

N3591P

Flight Phase:

Flight Type:

Ambulance

Survivors:

Site:

State College-University Park

Schedule:

Washington County – State College

MSN:

31-8012081

YOM:

1980

Location:

Pennsylvania

Country:

United States of America

Region:

North America

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

12493

Captain / Total hours on type:

718.00

Aircraft flight hours:

16040

Circumstances:

The commercial pilot was completing an instrument flight rules air taxi flight on a route that he had flown numerous times for the customer on board. Radar and voice communication data revealed that the airplane was vectored to the final approach course for the precision approach and was given a radio frequency change to the destination airport control tower frequency. The tower controller issued a landing clearance, which the pilot acknowledged; there were no further communications with the pilot. Weather conditions at the airport at the time of the accident included an overcast ceiling at 300 ft with 1 mile visibility in mist. The wreckage was located in densely-wooded terrain. Postaccident examination revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. The wreckage path and evidence of engine power displayed by numerous cut tree branches was consistent with a controlled, wings-level descent with power. A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach. Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed. The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain. It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined.

Probable cause:

The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain.

Final Report:

Crash of a Cessna 208B Grand Caravan EX in Lolat

Date & Time: Jun 14, 2016 at 0758 LT

Type of aircraft:

Cessna 208B Grand Caravan

Operator:

Registration:

PK-RCK

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Wamena – Lolat

MSN:

208B-5149

YOM:

2014

Location:

Lolat

Special Region of Papua

Country:

Indonesia

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

Circumstances:

The single engine airplane departed Wamena Airport at 0739LT on a cargo flight to Lolat, carrying two passengers, one pilot and a load of building materials for a total weight of 1,190 kilos. On short final to Lolat Airfield, the aircraft impacted the roof of a wooded house and crashed, bursting into flames. All three occupants of the airplane evacuated safely while three people in the house were injured. The aircraft was totally destroyed by a post crash fire.

Crash of an Antonov AN-32A in Bor

Date & Time: Jun 14, 2016

Type of aircraft:

Antonov AN-32

Operator:

Registration:

EK-32120

Flight Phase:

Flight Type:

Humanitarian

Survivors:

Site: