Crash of an Antonov AN-12BK in Juba: 41 killed

Date & Time: Nov 4, 2015 at 0900 LT
Type of aircraft:
Operator:
Registration:
EY-406
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Juba – Paloich
MSN:
01 34 77 04
YOM:
1971
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
37
Pax fatalities:
Other fatalities:
Total fatalities:
41
Circumstances:
After takeoff from Juba Airport Runway 13, the four engine aircraft encountered difficulties to gain height. After a distance of some 800 metres, the aircraft impacted a hill and crashed on the shore of the White Nile. Two passengers were seriously injured while 41 other occupants were killed, among them all six crew members. Weather conditions at the time of the accident were marginal with rain showers. South Sudan Authorities reported the aircraft was unable to climb because it was overloaded, and the captain reported to ATC prior to departure he was carrying 12 passengers. According to Antonov, the aircraft was not airworthy at the time of the accident because its owner, Tajik Asia Airways, was not compliant with published procedures.

Crash of a Boeing 737-4H6 in Lahore

Date & Time: Nov 3, 2015 at 0926 LT
Type of aircraft:
Operator:
Registration:
AP-BJO
Survivors:
Yes
Schedule:
Karachi – Lahore
MSN:
27166/2410
YOM:
1992
Flight number:
NL142
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
114
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19302
Captain / Total hours on type:
4859.00
Copilot / Total flying hours:
2076
Copilot / Total hours on type:
410
Aircraft flight hours:
51585
Aircraft flight cycles:
46547
Circumstances:
On 03rd November 2015, M/s Shaheen Air International Flight NL-142, Boeing 737-400 aircraft Reg # AP-BJO, was on a scheduled passenger flight from Karachi to Lahore. The flight landed on Runway 36L as Runway 36R was not available due to ILS CAT-III up-gradation. After touchdown, both main landing gears broke one after the other. Subsequently, the aircraft departed runway while resting on both engines and stopped 8302 ft from Runway Threshold (RWT), 197ft left of runway centreline. The nose landing gear, however, remained intact. All the passengers were safely evacuated through emergency procedure.
Probable cause:
The accident took place due to:
- Cockpit crew landing the aircraft through unstabilized approach (high ground speed and incorrect flight path).
- Low sink rate of left main landing gear (LMLG) as it touched down and probable presence of (more than the specified limits) play in the linkages of shimmy damper mechanism. This situation led to torsional vibrations / breakage of shimmy damper after touchdown. The resultant torsional excitation experienced by the LMLG due to free pivoting of wheels (along vertical axis) caused collapse of LMLG.
- The RMLG collapsed due to overload as the aircraft moved on unprepared surface.
Final Report:

Crash of a Grumman G-159 Gulfstream I in Kinshasa

Date & Time: Nov 1, 2015
Type of aircraft:
Operator:
Registration:
9Q-CNP
Survivors:
Yes
MSN:
164
YOM:
1965
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Kinshasa-Ndolo Airport, the crew reported technical problems with the undercarriage and was cleared to divert to Kinshasa-N'Djili Airport. A belly landing was completed on runway 24 and the aircraft slid for few dozen metres then veered off runway to the right and came to rest in a grassy area. All 26 occupants evacuated safely and the aircraft was damaged beyond repair. It is believed that the left main gear was torn off upon takeoff from Kinshasa-Ndolo Airport for unknown reasons.

Ground fire of a Boeing 767-269ER in Fort Lauderdale

Date & Time: Oct 29, 2015 at 1233 LT
Type of aircraft:
Operator:
Registration:
N251MY
Flight Phase:
Survivors:
Yes
Schedule:
Fort Lauderdale - Caracas
MSN:
23280/131
YOM:
1986
Flight number:
DYA405
Crew on board:
11
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15700
Copilot / Total flying hours:
4140
Aircraft flight hours:
30108
Aircraft flight cycles:
9986
Circumstances:
On October 29, 2015, about 12:33 pm eastern daylight time (EDT), Dynamic International Airways flight 405, a Boeing 767-200ER, N251MY, experienced a fuel leak and subsequent fire while taxiing for departure at the Fort Lauderdale-Hollywood International Airport, Florida (FLL). Of the 101 passengers and crew onboard, one passenger received serious injuries. The airplane sustained substantial damage from the fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 supplemental as a scheduled charter from FLL to Maiquetía Simón Bolívar International Airport (CCS), Caracas, Venezuela. A significant fuel leak and subsequent fire occurred in the left engine strut and nacelle during taxi, resulting in substantial damage to the airplane. The fuel leak was the result of a fuel line flexible coupling (Wiggins fitting) loosening and becoming disengaged due to the lack of a safety lockwire on the coupling as required by the maintenance manual. The leaking fuel contacted hot engine case surfaces which ignited the fire. Records indicate that maintenance was conducted on this fitting in October of 2012 at the 4C check prior to the airplane being prepared for storage. The area would also have been subject to a visual inspection when the airplane was brought out of storage in 2015. The same maintenance facility conducted both of these activities. About 240 flight hours were logged between the aircraft returning to service and the accident. The leak occurred after the coupling loosened due to the missing safety wire which was the result of an error by the third-party maintenance provider. The flight crew promptly shut down the left engine using the fire handle, and requested fire equipment. As the airplane stopped on the taxiway, passengers saw the fire and insisted that the cabin crew initiate an evacuation. One passenger opened an overwing exit on his own, and the slide did not deploy. The cabin crew initiated the evacuation without coordination with the flight crew. After the evacuation had already begun, the flight crew advised over the PA to evacuate out the right side of the airplane. The flight crew did not immediately shut down the right engine and an evacuating passenger ran behind the engine and was blown to the pavement resulting in serious injuries. The lack of coordination between the flight crew and cabin crew resulted in the evacuation initiating while the right engine was still running.
Probable cause:
The separation of the flexible fuel line coupling and subsequent fuel leak due to the failure of maintenance personnel to install the required safety lockwire. Contributing to the severity of the accident was the initiation of the evacuation before the right engine was shut down which led to the passenger's injury.
Final Report:

Crash of a Boeing 737-4L7 in Johannesburg

Date & Time: Oct 26, 2015 at 1206 LT
Type of aircraft:
Operator:
Registration:
ZS-OAA
Survivors:
Yes
Schedule:
Port Elizabeth - Johannesburg
MSN:
26960/2483
YOM:
1993
Flight number:
BA6234
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9186
Captain / Total hours on type:
2899.00
Copilot / Total flying hours:
5817
Copilot / Total hours on type:
480
Aircraft flight hours:
57543
Circumstances:
The aircraft Boeing 737-400, operated by Comair, flight number BA6234, was on a scheduled domestic flight operated under the provisions of Part 121 of the Civil Aviation Regulations (CARs). The aircraft was on the third leg for the day, after it had performed two uneventful legs. According to their recorded flight plan, the first leg departed from King Shaka International Airport (FALE) to O.R. Tambo International Airport (FAOR), the second leg was from FAOR to Port Elizabeth International Airport (FAPE) on the same day, during which the Captain was flying. During this third leg, the aircraft departed from FAPE at 0820Z on an instrument flight plan rule for FAOR. On board were six (6) crew members, ninety four (94) passengers and two (2) live animals. The departure from FAPE was uneventful, whereby the first officer (FO) was the flying pilot (FP) for this leg. During the approach to FAOR, the aircraft was cleared for landing on runway 03R. The accident occurred at approximately 1 km past the threshold. The crew stated that a few seconds after a successful touchdown, they felt the aircraft vibrating, during which they applied brakes and deployed the reverse thrust. The vibration was followed by the aircraft rolling slightly low to the left. It later came to a full stop slightly left of the runway centre line, resting on its right main landing gear and the number one engine, with the nose landing gear in the air. The crash alarm was activated by the FAOR Air Traffic Controller (ATC). The Airport Rescue and Fire Fighting (ARFF) personnel responded swiftly to the scene of the accident. The accident site was then secured with all relevant procedures put in place. The aircraft sustained substantial damage as the number one engine scraped along the runway surface when the landing gear detached from the fuselage. ARFF personnel had to prevent an engine fire in which they saw smoke as a result of runway contact. The occupants were allowed to disembark from the aircraft via the left aft door due to the attitude in which the aircraft came to rest. The accident occurred during daylight meteorological conditions on Runway 03R at O.R. Tambo International Airport (FAOR) located at GPS reading as: S 26°08’01.30” E 028°14’32.34” and the field elevation 5558 ft.
Probable cause:
Unstable approach whereby the aircraft was flared too high with high forward speed resulting with a low sink rate in which during touch down the left landing gear
experienced excessive vibration and failed due to shimmy events.
The following findings were identified:
- According to the FDR recordings, the aircraft flare was initiated earlier at 65ft than at 20ft as recommended by aircraft manufacture, which contributed to the low sink rate.
- The shimmy damper failed the post-accident lab-test and fluid was found in the thermal relief valve, which could have contributed to the shimmy damper failure.
- According to the lab results, significant wear was found on the upper torsion link bushing and flange, which could have contributed to undamped vibration
continuation.
- The aircraft had a tailwind component during landing, which could have prolonged the landing distance.
Final Report:

Crash of a Boeing 737-3K2 in Cuzco

Date & Time: Oct 23, 2015 at 1115 LT
Type of aircraft:
Operator:
Registration:
OB-2040-P
Survivors:
Yes
Schedule:
Lima - Cuzco
MSN:
24329/1858
YOM:
1990
Flight number:
P9216
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
133
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6352
Captain / Total hours on type:
1971.00
Copilot / Total flying hours:
1455
Copilot / Total hours on type:
1219
Aircraft flight hours:
74018
Aircraft flight cycles:
42389
Circumstances:
Following an uneventful flight from Lima, the crew started the descent to Cuzco-Alejandro Velasco Astete Airport Runway 28. On approach, the aircraft was configured for landing and flaps were deployed to 15°. Following a smooth landing, the crew started the braking procedure when, eight seconds after touchdown, he noticed vibrations coming from the left main gear. At a speed of 100 knots, the right main gear collapsed. The aircraft rolled for few hundred metres then came to a halt on the runway. All 139 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
Unstable approach and inadequate landing technique for high altitude fields, which resulted in increased landing speed, the start of the flare manoeuvre at higher altitude, and low descent speed, which made the OB-2040-P aircraft make soft contact with the runway, causing inefficiency in operation of the shimmy damper, which did not prevent uncontrolled oscillation of the shock absorbers.
Contributing factors:
- Lack of instruction and training in simulators that include techniques and maneuvers of landing at high altitude fields, with emphasis on speed control at landing.
- Lack of a performance analysis process, through the use of flight recorders or other installed data recording equipment and flight parameters, by the operating company, to enable supervision, control and corrective measures in the operational use of its aircraft.
Final Report:

Crash of a Learjet 35A in San Fernando

Date & Time: Oct 19, 2015 at 0640 LT
Type of aircraft:
Registration:
LV-ZSZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Fernando - Rio Gallegos
MSN:
35A-235
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9851
Captain / Total hours on type:
6200.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
39
Aircraft flight hours:
12190
Aircraft flight cycles:
9517
Circumstances:
The aircraft departed Buenos Aires-San Fernando Airport on a positioning flight to Río Gallegos, carrying two pilots. During the takeoff roll, the copilot (pilot-in-command) noticed that the left engine N1 reached a value of 101% instead of 95% like the right engine. At that point the aircraft had already traveled 380 metres. As the aircraft started to veer to the right, the copilot decided to abandon the takeoff procedure without informing the captain. The power levers were brought back to idle and the copilot started to brake. After a course of about 980 metres, the right engine N1 value dropped to 30-40% while the left engine remained at 101%. Then the captain took over control, deployed briefly the thrust reverser system when the aircraft departed the runway to the right. While rolling in a grassy area, it struck a drainage ditch located 80 metres from the runway, lost its undercarriage then slid for few dozen metres before coming to rest, bursting into flames. Both pilots evacuated safely while the aircraft was destroyed by a post crash fire.
Probable cause:
The most likely cause of the uncommanded acceleration and subsequent overspeed condition was a contamination of retained particles present within the fuel control unit (FCU). The contamination was a short-lived random condition, as evidenced by the fact that after about 30 seconds the power lever regained control of the left engine. On a general aviation flight, during the take-off run, the LJ35 LV-ZSZ suffered a runway excursion on the right side, and a subsequent aircraft fire.
The accident was due to the combination of the following factors:
- The uncommanded acceleration of the left engine at the start of the take-off run,
- The initial lack of response of the left engine to the requests of the corresponding power lever,
- The difficulties of the crew in managing an unusual condition of the aircraft in accordance with guidelines established in the AFM,
- The ambivalence in the existing regulations for the authorization of a co-pilot in an aircraft that require two pilots for certification,
- The duality in the application of safety standards allowed by the existing normative regulations.
Although unrelated, the state of the runway 05/23 protection zone at the San Fernando Aerodrome contributed to the severity of the accident.
Final Report:

Crash of a Comp Air CA-8 in Ray

Date & Time: Oct 15, 2015 at 1810 LT
Type of aircraft:
Operator:
Registration:
N224MS
Survivors:
Yes
Schedule:
Anniston - Ray
MSN:
0652843
YOM:
2006
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
948
Captain / Total hours on type:
49.00
Circumstances:
The private pilot reported that, while on a left downwind in the airport traffic pattern after conducting a cross-country business flight, he extended the flaps 10 degrees. While on short final, he fully extended the flaps, and shortly after, the left wing dropped. The pilot attempted to correct the left wing drop by applying right aileron and rudder; however, the airplane did not respond. The pilot chose to conduct a go-around and increased engine power. The airplane subsequently pitched up, and the left turn steepened. The pilot subsequently reduced engine power, and the airplane began to descend. The airplane struck the ground short of the runway, and the left wing separated from the fuselage. The examination of the airframe, flight controls, and engine revealed no preimpact mechanical anomalies that would have precluded normal operation. Examination of the trim system revealed that the right aileron trim and the left rudder trim were in positions that would have resulted in a right turn and a left yaw. Further, a witness reported that the airplane appeared to be in a cross-controlled attitude while on final approach to the airport. It is likely that the pilot’s improper use of the trim led to a cross-controlled situation and resulted in the subsequent stall during the attempted go-around.
Probable cause:
The pilot's improper use of the trim, which created a cross-controlled situation and resulted in an aerodynamic stall during the attempted go-around.
Final Report:

Crash of a Cessna 421B Golden Eagle II in Hammond: 2 killed

Date & Time: Oct 14, 2015 at 1548 LT
Operator:
Registration:
N33FA
Flight Phase:
Survivors:
No
Schedule:
Hammond - Atlanta
MSN:
421B-0502
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin-engine airplane, flown by a commercial pilot, was departing on a business flight from runway 31 when the right engine lost power. According to a pilot-rated witness, the airplane was about halfway down the 6,500 ft runway at an altitude of about 100 ft above ground level when he heard a "loud pop" and then saw the airplane's right propeller slow. The witness reported that the airplane yawed to the right and then began a right turn toward runway 18 with the right engine's propeller windmilling. The witness further reported that the airplane cleared a tree line by about 150 ft, rolled right, descended straight down to ground impact, and burst into flames. Postaccident examination of the airplane's right engine revealed that the crankshaft was fractured adjacent to the No. 2 main bearing, which had rotated. The crankcase halves adjacent to the No. 2 main bearing were fretted where the case through-studs were located. The fretting of the mating surfaces was consistent with insufficient clamping force due to insufficient torque of the through-stud nuts. Records indicated that all six cylinders on the right engine had been replaced at the airplane's most recent annual inspection 8 months before the accident. In order to replace the cylinders, the through-stud nuts had to be removed as they also served to hold down the cylinders. It is likely that when the cylinders were replaced, the through-stud nuts were not properly torqued, which, over time, allowed the case halves to move and led to the bearing spinning and the crankshaft fracturing. During the accident sequence, the pilot made a right turn in an attempt to return to the airport and did not feather the failed (right) engine's propeller, allowing it to windmill, thereby creating excessive drag. It is likely that the pilot allowed the airspeed to decay below the minimum required for the airplane to remain controllable, which combined with his failure to feather the failed engine's propeller and the turn in the direction of the failed engine resulted in a loss of airplane control.
Probable cause:
The loss of right engine power on takeoff due to maintenance personnel's failure to properly tighten the crankcase through-studs during cylinder replacement, which resulted in crankshaft fracture. Also causal were the pilot's failure to feather the propeller on the right engine and his failure to maintain control of the twin-engine airplane while maneuvering to return to the airport.
Final Report:

Crash of a BAe 146-300 in Tamale

Date & Time: Oct 6, 2015 at 0831 LT
Type of aircraft:
Operator:
Registration:
9G-SBB
Survivors:
Yes
Schedule:
Accra – Tamale
MSN:
E.3123
YOM:
1989
Flight number:
IKM110
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
71
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 23 at Tamale Airport, the four engine aircraft failed to stop within the remaining distance. It went through a fence that was delimiting a work area as the runway was subject to an extension. Upon impact, the nose gear was torn off and the aircraft slid for few dozen metres before coming to rest. All 76 occupants escaped uninjured but the aircraft was damaged beyond repair. It was specified in a NOTAM that the runway 23 length was reduced to 1,860 meters and that works were in progress to extend runway 23, with the presence of men and equipment. So, caution was advised during landing and takeoff procedures.