Crash of a Beechcraft 1900D in Naypyidaw: 5 killed

Date & Time: Feb 10, 2016 at 0940 LT
Type of aircraft:
Operator:
Registration:
4601
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Naypyidaw – Namhsan
MSN:
UE-177
YOM:
1995
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Shortly after takeoff from Naypyidaw Airport, while climbing to an altitude of about 500 feet, the aircraft entered an uncontrolled descent and crashed in an open field located 600 metres past the runway end, bursting into flames. Four occupants were killed while a passenger was seriously injured and evacuated to a local hospital. He died from his injuries few hours later. Used for emergency flights, the airplane was carrying three officers to Namhsan, Shan State, to assist with the aftermath of a fire there. Those officers who were killed were Major Aung Kyaw Moe, Captain Aung Paing Soe and Captain Htin Kyaw Soe.

Crash of a Rockwell Sabreliner 75A in Santiago de Querétaro

Date & Time: Jan 30, 2016 at 0738 LT
Type of aircraft:
Operator:
Registration:
N380CF
Flight Type:
Survivors:
Yes
Schedule:
Celaya - Santiago de Querétaro
MSN:
380-51
YOM:
1977
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
10195
Circumstances:
The aircraft, a Rockwell Sabreliner 75A (NA-265-80 version) departed Celaya-Capitán Rogelio Castillo Airport shortly before 0700LT on a short flight to Santiago de Querétaro without any flight plan and with an unknown number of people on board. At 0731LT, the crew contacted the destination airport and elected to land about seven minutes later. After landing on runway 27, the crew was instructed to vacate via taxiway for the apron but the aircraft continued, veered off runway after a distance 800 metres, impacted a rocky wall, lost its nose gear and came to rest. When the rescuers arrived on the scene, there was nobody as the occupants left the airplane and disappeared. It appears the flight was illegal and it is believed that the aircraft was stolen at Celaya Airport.

Crash of a Cessna 425 Conquest in Windhoek: 3 killed

Date & Time: Jan 29, 2016 at 1010 LT
Type of aircraft:
Operator:
Registration:
V5-MJW
Flight Type:
Survivors:
No
Schedule:
Windhoek - Windhoek
MSN:
425-0077
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11686
Copilot / Total flying hours:
3765
Copilot / Total hours on type:
256
Aircraft flight hours:
10108
Circumstances:
On 29 January 2016, at 08:10 a Cessna 425 Conquest, which was privately operated, crashed approx. 300 meters NNE of threshold Runway 26. 1.1.2 According to the flight plan filled on the 28th January 2016, the flight was scheduled for a renewal of CPL and IR ratings for the two pilots by a Designated Examiner (DE). Departure time was scheduled at 07:45 at a cruising altitude of FL100 for Hosea Kutako Airport. The pilots requested a procedure for an Instrument Landing System (ILS) approach. The Air Traffic Controller (ATC) cleared them for the procedure for runway 26 ILS approach with QNH 1024. They were also asked to report when at nine miles-inbound. At around nine miles they reported their location and were instructed to continue the approach along the glide slope. The DE requested a VOR approach for their next approach and an early right hand turnout that was approved by ATC who also required them to report when going around. The ATC stated that he saw them at around 4nm on final approach. He then stated that he looked away for a moment after which he heard a slight bang, then saw a ball of flames at about 300 meters north of threshold runway 26. He called out to the aircraft three times whilst looking out for it when he finally concluded that it could have been V5-MJW that had crashed. The ATC pressed a crash alarm after a moment when it did not go off, the controller then called the fire station and alerted them of the occurrence. The Airport’s Fire and Rescue team after receiving the initial notification from the ATC took around 10 minutes to reach the site, by that time fire had engulfed the plane and its occupants. The team took 3-4 minutes to extinguish the fire. The weather was reported as fine with winds about 140° at 08 kts with scattered clouds at 4000ft and unrestricted visibility.
Probable cause:
The aircraft stalled at low altitude and consequently impacted the ground.
Contributory Factors:
- Loss of control of the aircraft,
- Non-adherence of go-around procedures as set on the AIP,
- Normalization of deviation -where non-standard go-around procedures are executed.
Final Report:

Crash of a McDonnell Douglas MD-83 in Mashhad

Date & Time: Jan 28, 2016 at 1937 LT
Type of aircraft:
Operator:
Registration:
EP-ZAB
Survivors:
Yes
Schedule:
Isfahan – Mashhad
MSN:
49930/1720
YOM:
1990
Flight number:
ZV4010
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
154
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9224
Captain / Total hours on type:
4341.00
Copilot / Total flying hours:
633
Copilot / Total hours on type:
471
Aircraft flight hours:
51446
Aircraft flight cycles:
30255
Circumstances:
Following an uneventful flight from Isfahan, the crew initiated the approach to Mashhad Airport by night and poor weather conditions with low visibility due to snow falls. After touchdown on runway 31R, the crew started the braking procedure and activated the reverse thrust systems. The aircraft skidded then veered off runway to th left, lost its both main undercarriage and came to rest 55 metres to the left of the runway, some 1,311 metres from the runway threshold. All 162 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Loss of control after touchdown due to an abnormal use by the captain of the reverse thrust systems, which caused the aircraft to slid and to become out of control,
- Weather conditions deteriorated with a sudden drop in temperature and a reduced visibility,
- Limited RVR to 811 metres,
- The crew failed to initiate a go-around procedure,
- Overconfidence on part of the captain due to his high experience,
- Poor crew resource management,
- The braking coefficient was low due to an excessive deposit of rubber on the runway surface, combined with a layer of snow that the airport authorities did not consider necessary to clear in due time.
Final Report:

Ground accident of a Pilatus PC-12/47E in Savannah

Date & Time: Jan 6, 2016 at 0835 LT
Type of aircraft:
Operator:
Registration:
N978AF
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Savannah - Lexington
MSN:
1078
YOM:
2008
Flight number:
Cobalt Air 727
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23141
Captain / Total hours on type:
534.00
Copilot / Total flying hours:
7900
Copilot / Total hours on type:
5100
Aircraft flight hours:
4209
Circumstances:
The aircraft collided with a ditch during a precautionary landing after takeoff from Savannah/Hilton Head International Airport (SAV), Savannah, Georgia. The pilot and copilot sustained minor injuries, and the airplane was substantially damaged. The airplane was registered to Upper Deck Holdings, Inc. and was being operated by PlaneSense, Inc,. as a Title 14 Code of Federal Regulations Part 91 positioning flight. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight to Blue Grass Airport (LEX), Lexington, Kentucky. The pilot in the left seat was the pilot monitoring and the copilot in the right seat was the pilot flying. The crew had the full length of the runway 1 available (7,002 ft) for takeoff. The pilots reported that the acceleration and takeoff was normal and after establishing a positive rate of climb, the crew received an auditory annunciation and a red crew alerting system (CAS) torque warning. The engine torque indicated 5.3 pounds per square inch (psi); the nominal torque value for the conditions that day was reported by the crew to be 43.3 psi. With about 2,700 ft of runway remaining while at an altitude of 200 ft msl, the copilot elected to land immediately; the copilot pushed the nose down and executed a 90° left descending turn and subsequently landed in the grass. Although he applied "hard" braking in an attempt to stop, the airplane impacted a drainage ditch, resulting in substantial impact damage and a postimpact fire. The pilot reported that, after takeoff, he observed a low torque CAS message and the copilot told him to "declare an emergency and run the checklist." The pilot confirmed that the landing gear were extended and the copilot turned the airplane to the left toward open ground between the runways and the terminal. About 60 seconds elapsed from the start of the takeoff roll until the accident. The airport was equipped with security cameras that captured the airplane from its initial climb through the landing and collision. One camera, pointed toward the west-southwest, recorded the airplane's left descending turn and its landing in the grass, followed by impact and smoke. A second camera, mounted on the control tower, pointed toward the southeast and showed the airplane during the initial climb before it leveled off and entered a descending left turn; it also showed the airplane land and roll through the grass before colliding with the ditch.
Probable cause:
The pilots' failure to follow proper procedures in response to a crew alerting system warning for high engine torque values, which necessitated an off-runway emergency landing during which the airplane sustained substantial damage due to postimpact fire. Contributing to the accident was the erroneous engine torque indication for reasons that could not be determined.
Final Report:

Crash of an Airbus A310-304F in Mbuji-Mayi: 8 killed

Date & Time: Dec 24, 2015 at 1630 LT
Type of aircraft:
Operator:
Registration:
9Q-CVH
Flight Type:
Survivors:
Yes
Schedule:
Lubumbashi – Mbuji-Mayi
MSN:
413
YOM:
1986
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The crew completed the approach and landing on runway 17 in poor weather conditions with heavy rain falls. After touchdown on a wet runway surface, the aircraft was unable to stop within the remaining distance (runway 17 is 2,000 metres long). It overran and collided with several houses before coming to rest 300 metres further. All five crew members evacuated safely while eight people on the ground were killed.

Crash of a Piper PA-46-500TP Malibu Meridian in Corinth

Date & Time: Dec 24, 2015 at 0840 LT
Registration:
N891CR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Corinth - Key Largo
MSN:
46-97321
YOM:
2007
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1990
Captain / Total hours on type:
427.00
Aircraft flight hours:
1407
Circumstances:
On the day of the accident, a line service technician had disconnected the airplane from a battery charger. After disconnecting the battery, he left the right access door open which provided access to the fuel control unit, fuses, fuel line, oil line, and battery charging port as he always did. He then towed the airplane from the hangar it was stored in, and parked it in front of the airport's terminal building. The three passengers arrived first, and then about 30 minutes later the pilot arrived. He uploaded his navigational charts and did a preflight check "which was normal." The engine start, taxi, and engine run up, were also normal. The wing flaps were set to 10°. After liftoff he "retracted the landing gear" and continued to climb. Shortly thereafter the right cowl door opened partially, and started "flopping" up and down 3 to 4 inches in each direction. He reduced the torque to try to prevent the right cowl door from coming completely open. However, when he turned on the left crosswind leg to return to the runway, the right cowl door opened completely, and the airplane would not maintain altitude even with full power, so he "put the nose back down." The airplane struck trees, and then pancaked, and slid sideways and came to rest, in the front yard of an abandoned house. The private pilot and one passenger received minor injuries. Two passengers received serious injuries, one of whom was found out of her seat, unconscious, on the floor of the airplane shortly after the accident, and died about 227 days later. During the investigation, it could not be determined, if she had properly used the restraint system, as it was found unlatched with the seatbelt portion of the assembly extended. Examination of the wreckage revealed no evidence of any preimpact failures or malfunctions of the airplane or engine that would have precluded normal operation. It was discovered though, that the right access door had not been closed and latched by the pilot before takeoff, as examination of the right access door latches and clevis keepers found them to be functional, with no indication of overstress or deformation which would have been present if the access door had been forced open due to air loads in-flight, or during the impact sequence. Further examination also revealed that the battery charging port cover which was inside the compartment that the right access door allowed access to, had not been placed and secured over the battery charging port, indicating that the preflight inspection had not been properly completed. A checklist that was provided by a simulator training provider was found by the pilot's seat station. Examination of the checklist revealed that under the section titled: "EXTERIOR PREFLIGHT" only one item was listed which stated, "EXTERIOR PREFLIGHT…COMPLETE." It also stated on both sides of the checklist: "FOR SIMULATOR TRAINING PURPOSES ONLY." A copy of the airplane manufacturer's published pilot's operating handbook (POH) was found in a cabinet behind the pilot's seat where it was not accessible from the pilot's station. Review of the POH revealed that it contained detailed guidance regarding the preflight check of the airplane. Additionally, it was discovered that the landing gear was in the down and locked position which would have degraded the airplane's ability to accelerate and climb by producing excess drag, and indicated that the pilot had not retracted the landing gear as he thought he did, as the landing gear handle was still in the down position. Review of recorded data from the airplanes avionics system also indicated that the airplane had roughly followed the runway heading while climbing until it reached the end of the runway. The pilot had then entered a left turn and allowed the bank angle to increase to about 45°, and angle of attack to increase to about 8°, which caused the airspeed to decrease below the stalling speed (which would have been about 20% higher than normal due to the increased load factor from the steep turn) until the airplane entered an aerodynamic stall, indicating that the pilot allowed himself to become distracted by the open door, rather than maintaining control of the airplane. One of the seriously injured passenger passed away 227 days after the accident.
Probable cause:
The pilot's inadequate preflight inspection and his subsequent failure to maintain airplane control, which resulted in an access door opening after takeoff, and the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.
Final Report:

Crash of a Beechcraft BeechJet 400A in Telluride

Date & Time: Dec 23, 2015 at 1415 LT
Type of aircraft:
Operator:
Registration:
XA-MEX
Survivors:
Yes
Schedule:
Monterrey – El Paso – Telluride
MSN:
RK-396
YOM:
2004
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7113
Captain / Total hours on type:
1919.00
Copilot / Total flying hours:
8238
Copilot / Total hours on type:
1412
Aircraft flight hours:
5744
Circumstances:
The pilots were conducting an international chartered flight in the small, twin-engine jet with five passengers onboard. Since the weather at the destination was marginal, the flight crew had discussed an alternate airport in case weather conditions required a missed approach at their destination. As the airplane neared the non-towered destination airport, the flight crew received updated weather information, which indicated that conditions had improved. Upon contacting the center controller, the crew was asked if they had the weather and NOTAMS for the destination airport. The crew reported that they received the current weather information, but did not state if they had NOTAM information. The controller responded by giving the flight a heading for the descent and sequence into the airport. The controller did not provide NOTAM information to the pilots. About 2 minutes later, airport personnel entered a NOTAM via computer closing the runway, effective immediately, for snow removal. Although the NOTAM was electronically routed to the controller, the controller's system was not designed to automatically alert the controller of a new NOTAM; the controller needed to select a display screen on the equipment that contained the information. At the time of the accident, the controller's workload was considered heavy. About 8 minutes after the runway closure NOTAM was issued, the controller cleared the airplane for the approach. The flight crew then canceled their instrument flight plan with the airport in sight, but did not subsequently transmit on or monitor the airport's common traffic advisory frequency, which was reportedly being monitored by airport personnel and the snow removal equipment operator. The airplane landed on the runway and collided with a snow removal vehicle about halfway down the runway. The flight crew reported they did not see the snow removal equipment. The accident scenario is consistent with the controllers not recognizing new NOTAM information in a timely manner due to equipment limitations, and the pilots not transmitting or monitoring the common traffic advisory frequency. Additionally, the accident identifies a potential problem for flight crews when information critical to inflight decision-making changes while en route, and problems when controller workload interferes with information monitoring and dissemination.
Probable cause:
The limitations of the air traffic control equipment that prevented the controller's timely recognition of NOTAM information that was effective immediately and resulted in the issuance of an approach clearance to a closed runway. Also causal was the pilots' omission to monitor and transmit their intentions on the airport common frequency. Contributing to the accident was the controller's heavy workload and the limitations of the NOTAM system to distribute information in a timely manner.
Final Report:

Crash of a Embraer ERJ-190-200LR in Kupang

Date & Time: Dec 21, 2015 at 1746 LT
Type of aircraft:
Operator:
Registration:
PK-KDC
Survivors:
Yes
Schedule:
Ende - Kupang
MSN:
190-00057
YOM:
2006
Flight number:
KD676
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
120
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9800
Captain / Total hours on type:
598.00
Copilot / Total flying hours:
2997
Copilot / Total hours on type:
557
Aircraft flight hours:
16862
Aircraft flight cycles:
14765
Circumstances:
On 21 December 2015, an ERJ 190-200 (Embraer 195) aircraft, registered PK-KDC, was being operated by Kalstar Aviation on a scheduled passenger flight. The crew was scheduled to fly three sectors from I Gusti Ngurah Rai International Airport (WADD) Bali – H. Hasan Aroeboesman Airport (WATE) Ende – El Tari International Airport (WATT) Kupang – Sultan Hasanuddin International Airport (WAAA), Makassar. The aircraft departed Bali at 0734 UTC which was delayed for 74 minutes from the normal schedule, due to late arrival of the aircraft from the previous flight. On the flight from Bali to Ende, the Pilot in Command (PIC) acted as pilot monitoring (PM) and the Second in command (SIC) acted as pilot flying (PF). The aircraft landed in Ende at 0839 UTC. During transit, the PIC received a short message from a flight operations officer of Kalstar Aviation in Kupang which informed him that the visibility at Kupang was 1 km. Considering the weather forecast in the Terminal Aerodrome Forecast (TAFOR) showed that the visibility at Kupang would improve at the time of arrival, the PIC decided to depart to Kupang. Another consideration was the operating hours of Ende which would be closed at 0900 UTC. The operating hours of Ende was extended and the aircraft departed Ende at 0916 UTC, with flight number KD676. On board this flight were two pilots, three flight attendants, and 125 passengers. The PIC acted as PM and the SIC acted as PF. There was no departure briefing performed by the PF. After takeoff, the pilot set the Flight Management System (FMS) to fly direct to KPG VOR and climbed to a cruising altitude of Flight Level (FL) 175 (17,500 feet). During climbing, the PIC instructed the SIC to reduce the aircraft speed by 20 knots with the intention to wait for the weather improvement at Kupang. During cruising, the pilots monitored communication between El Tari Tower controller with another pilot. El Tari Tower controller advised that the visibility at Kupang was 1 km while the minima for approach was 3.9 km. At 0927 UTC, the pilot established communication with El Tari Tower controller and requested for direct to initial approach point SEMAU. At 0932 UTC, the aircraft was at 62 Nm, the aircraft started to descend which was approved to 10,000 feet. When the aircraft passed FL 150, the pilot requested to turn left to fly direct to the inbound track of the VOR/DME approach for runway 07 in order to avoid cloud formation which was indicated by magenta color on the aircraft weather radar. At 0941 UTC, the El Tari Tower controller informed that the visibility on runway 07 was 4 km and issued clearance for RNAV approach to runway 07 and requested that the pilot report when the runway was in sight. Both pilots discussed the plan to make an RNAV approach to runway 07, with landing configuration with flap 5 and auto-brake set to position low. At 0943 UTC, the pilot reported that the runway was in sight when passing 2,500 feet and the El Tari Tower controller informed that the wind was calm and issued a landing clearance. During the approach, the PF noticed that all Precision Approach Path Indicator (PAPI) lights indicated a white color, which indicated that the aircraft was too high for the approach. Recognizing that the aircraft was too high, the crew performed a non-standard configuration setting by extending the landing gear down first with the intention to increase drag. The landing gear was extended at approximately 7 Nm from the runway 07 threshold and afterwards selected the flaps to 1 and 2. The published approach procedure stated that the sequence for establishing landing configuration is by selecting flap 1, flap 2, landing gear down, flap 3 and flap 5. On final approach, the crew noticed the aural warning “HIGH SPEED HIGH SPEED”. The SIC also noticed that the aircraft speed was about 200 knots. The pilots decided to continue the approach considering the runway was 2,500 meters long and would be sufficient for the aircraft to stop with the existing conditions. The pilots compared the runway condition at Kupang with the condition at Ende which had 1,650 meter length runway. On short final approach, the aircraft was on the correct glide path and the speed was approximately 205 knots. The PF noticed the Enhanced Ground Proximity Warning System (EGPWS) warning of “TOO LOW TERRAIN” activated. The aircraft then touched down at approximately the middle of the runway. After touchdown, the PF immediately applied thrust reverser. Realizing that the aircraft was about to overrun the end of the runway, and with the intention to avoid the approach lights on the end of the runway, the PIC turned the aircraft to the right. The aircraft stopped approximately 200 meters from the end of runway 07. At 0946 UTC, the El Tari Tower controller saw the aircraft overrun, then pushed the crash bell and informed the Airport Rescue and Fire Fighting (ARFF).
Probable cause:
Contributing Factors:
- The steep authority gradient resulted in lack of synergy that contributed to least of alternation to correct the improper condition.
- Improper flight management on approach resulted to the aircraft not fully configured for landing, prolong and high speed on touchdown combined with low brake pressure application resulted in insufficient runway for deceleration.
- The deviation of pilot performance was undetected by the management oversight system.
Final Report:

Ground accident of a Boeing 737-3H4 in Nashville

Date & Time: Dec 15, 2015 at 1730 LT
Type of aircraft:
Operator:
Registration:
N649SW
Flight Phase:
Survivors:
Yes
Schedule:
Houston – Nashville
MSN:
27719/2894
YOM:
1997
Flight number:
WN031
Crew on board:
5
Crew fatalities:
Pax on board:
133
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19186
Captain / Total hours on type:
14186.00
Copilot / Total flying hours:
15500
Copilot / Total hours on type:
5473
Aircraft flight hours:
58630
Circumstances:
On December 15, 2015, at 5:23pm central standard time (CST), Southwest Airlines flight 31, a Boeing 737-300, N649SW, exited the taxiway while taxing to the gate and came to rest in a ditch at the Nashville International Airport (BNA), Nashville, Tennessee. Nine of the 138 passengers and crew onboard received minor injuries during the evacuation and the airplane was substantially damaged. The airplane was operating under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from William P. Hobby Airport (HOU), Houston, Texas. Weather was not a factor, light conditions were dark just after sunset. The airplane landed normally on runway 20R and exited at taxiway B2. The flight crew received and understood the taxi instructions to their assigned gate. As the crew proceeded along taxiway T3, the flight crew had difficulty locating taxiway T4 as the area was dark, and there was glare from the terminal lights ahead. The crew maneuvered the airplane along T3 and onto T4, and then turned back to the right on a general heading consistent with heading across the ramp toward the assigned gate. The flight crew could not see T4 or the grassy area because the taxiway lights were off and the glare from the terminal lights. As a result, the airplane left the pavement and came to rest in a drainage ditch resulting in substantial damage to airplane. The cabin crew initially attempted to keep the passengers seated, but after being unable to contact the flight crew due to the loud alarm on the flight deck, the cabin crew properly initiated and conducted an evacuation. As a result of past complaints regarding the brightness of the green taxiway centerline lights on taxiways H, J, L and T-6, BNA tower controllers routinely turned off the taxiway centerline lighting. Although the facility had not received any requests on the day of the accident, about 30 minutes prior to the event the tower controller in charge (CIC) turned off the centerline lights as a matter of routine. In doing so, the CIC inadvertently turned off the "TWY J & Apron 2" selector, which included the taxiway lights in the vicinity of the excursion. The airfield lighting panel screensaver feature prevented the tower controllers from having an immediate visual reference to the status of the airfield lighting.
Probable cause:
The flight crew's early turn towards the assigned gate because taxiway lighting had been inadvertently turned off by the controller-in-charge which resulted in the airplane leaving the paved surface. Contributing to the accident was the operation of the screen-saver function on the lighting control panel that prevented the tower controllers from having an immediate visual reference
to the status of the airfield lighting.
Final Report: