Airport (less than 10 km from airport)

A Kodiak-100 aircraft, registered PK-SDF, on 9 April 2014 was being operated by PT. Adventist Aviation Indonesia as non-schedule flight from Doyo Baru Airstrip with intended destination of Ninia Airstrip, Papua. On board in this flight were 7 persons consist of one pilot and six passengers. This flight was the fourth flights for the pilot who has performed flights from Doyo Baru (DOB) – Puldamat (PUL) at 2138-2228 UTC; Puldamat (PUL) –Soya (SOY) at 2243-2247 UTC; Soya (SOY) – Doyo Baru (DOB) at 2256-2344 UTC. The flight time to destination was estimated of 1 hour with cruising altitude of 10,000 feet and the fuel on board were sufficient for 4 hours flight time. Doyo Baru Airstrip located at approximately 10 NM North West of Sentani Airport (WAJJ). Air traffic movement to and from Doyo Baru Airstrip was controlled by Sentani Tower controller. At 0015 UTC, the pilot contacted to Sentani Tower controller, requested for start engine and clearance to fly to Ninia. The requests were approved and to report when ready for departure. At 0021 UTC, the pilot reported to the Sentani Tower controller ready for departure from Doyo Baru Airstrip. The Sentani Tower Controller instructed the pilot to hold to wait an aircraft took off from Sentani Airport. At 0024 UTC, the pilot received clearance for takeoff with additional traffic information and to report after airborne. At 0027 UTC, Sentani Tower controller has not received reports from the PK-SDF pilot and tried to call but was not responded. After several observations toward Doyo Baru area and did not see PK-SDF aircraft, The Sentani Tower controller reported to the Chief Section of Sentani Tower Air Navigation. At 0030 UTC, The Chief Section of Sentani Tower Air Navigation clarified the condition of PK-SDF aircraft to one of Indonesian Adventist Aviation pilot in Doyo Baru and obtained information that the aircraft had experienced in accident during takeoff at Doyo Baru. An engineer after received the information went to the accident site and saw appearance of white smoke came out from the side of the river which was known as the accident aircraft located. After arrived at the accident site the engineer saw the Adventist’s staffs and local people tried to extinguish the fire on the aircraft engine by throwing some water and used two fire extinguishers while some people moved the passengers from the wreckage. Two occupants including the pilot were fatally injured and five other passengers were seriously injured. All occupants were taken to Yowari Hospital (Rumah Sakit Umum Daerah – RSUD Yowari).

The aircraft took off from the Senador Nilo Coelho Aerodrome (SBPL), Petrolina - PE, to Presidente Juscelino Kubitschek International Airport (SBBR), Brasilia - DF, at 1752 (UTC), in order to complete the scheduled cargo and personnel flight O6 6393, with 5 crewmembers and 44 passengers on board. During the level flight, thirty minutes after takeoff, the aircraft presented low level in the hydraulic system 1. The crew performed the planned operational procedures and continued the flight to Brasilia, with the hydraulic system degraded. During the SBBR landing procedures, the crew used the alternative system for lowering the landing gears. The main landing gears lowered and locked, the nose landing gear unlocked, but did not lower. After coordination with the air traffic control, the aircraft was instructed to land on SBBR runway 11R. The landing took place at 2042 (UTC). After the touchdown, the aircraft covered a total distance of 900 meters until its full stop. The initial 750 meters were with the aircraft supported only by the main landing gears and the last 150 meters were with the aircraft supported by the main landing gears and by the lower part of the front fuselage. The aircraft stopped on the runway. Substantial damage to structural elements of the aircraft occurred near the nose section. The evacuation of the crewmembers and passengers was safe and orderly. The copilot suffered fractures in the thoracic spine. The other crewmembers and passengers left unharmed.

On 25.03.2014, the operator received the travel programme for 27.3.2014, of Hon'ble Governor of Haryana from Chandigarh to Delhi. On 26.3.2014, the operations department took the flight clearances and filed the passenger manifest with the ATC and other concerned agencies. The flight plan was filed by a CPL holder, who is working as flight dispatcher with the Government of Haryana. The departure on 27.3.2014 was fixed at 1130 hrs. The cockpit crew reported at 1045 hrs for the flight. Pre flight medical examination including the breath analyzer test was carried out at 1100 hrs. The breath analyzer test for both the cockpit crew members was negative. Pre flight briefing among the crew members was carried out by using the documents prepared by the flight dispatcher. The aircraft was taxied under its own power from Haryana Government Hangar to bay no. D-2 in front of ATC building. No abnormality was observed or reported on the aircraft during this taxiing. The engines were shut down for passenger embarkation. As per the passenger manifest, in addition to the pilot and co-pilot there were 8 passengers. The baggage on board was approx. 50 lbs. There was 2100 lbs. of fuel on board. After boarding of the passengers, the aircraft engines were started at 1130 hrs. The aircraft was cleared for departure abeam „D‟ link. The aircraft was taxied out via taxiway „D‟. After ATC departure clearance the aircraft was lined up for take-off. On clearance from ATC the take off roll was initiated and all the parameters were found normal. As per the pilot just before getting airborne some stiffness was found in rudder control as is felt in yaw damper engagement. The aircraft then pulled slightly to the left which as per the Commander was controllable. As per the pilot, the rotation was initiated at 98 knots. As per the DATCO the aircraft had lifted up to 10-15 feet AGL. The Commander has stated that after lift-off, immediately the left rudder got locked in forward position resulting in the aircraft yawing and rolling to left. The pilots tried to control it with right bank but the aircraft could not be controlled. Within 3-4 seconds of getting airborne the aircraft impacted the ground in left bank attitude. The initial impact was on pucca (tar road) and the wing has taken the first impact loads with lower surface metallic surface rubbing and screeching on ground. After the aircraft came to final halt, the co-pilot opened the door and evacuation was carried out. There was no injury to any of the occupants. The engine conditions lever could not be brought back as these were stuck. The throttle and pitch levers were retarded. The fuel shut off valves were closed. Battery and avionics were put off. Friction lock nuts were found loose. As per the Commander, after ensuring safety of passengers he had gone to cockpit to confirm that all switches were „off‟. At that time he has loosened the friction lock nuts to bring back the condition lever and throttle lever. However even after loosening the nut it was not possible to bring back these levers. Fire fighting vehicles were activated by pressing crash bell and primary alarm. Hand held RT set was used to announce the crash. RCFF vehicles proceeded to the site via runway and reported all the 10 personnel are safe and out of the disabled aircraft. Water and complementary agents (foam and dry chemical powder) were used. After fire was extinguished, the Fire Fighting vehicles reported back at crash bay except one CFT which was held at crash site under instruction of COO. The aircraft was substantially damaged. There was no fire barring burning of small patch of grass due coming in contact with the hot surfaces and oil. There was no injury to any of the occupants. The accident occurred in day light conditions.

Following an uneventful flight from Cannes-Mandelieu Airport, the pilot initiated the approach to Barcelonnette-Saint-Pons Airport Runway 27. Following an unstabilized approach, the aircraft landed hard, causing the left main gear to collapse. The aircraft veered off runway to the left, lost its right main gear and came to rest. There was no fire. All five occupants escaped uninjured and the aircraft was damaged beyond repair.

According to the pilot, he checked the fuel gauges before departure and believed he had enough fuel for the flight. As he approached his destination airport, he was instructed by an air traffic controller to enter a 2-mile left base. About 3 miles from the airport, the controller advised him to intercept a 6-mile final. About 1 1/2 miles from the runway, the left engine “quit.” The pilot repositioned the fuel valve to the left inboard fuel tank and was able to restart the engine, but, shortly after, the right engine “quit.” He then attempted to reposition the right fuel valve to the right inboard fuel tank to restart the right engine, but the left engine “quit” again, and the pilot subsequently made a forced landing in a field. An examination of the engine and airplane systems revealed no anomalies that would have precluded normal operation. The left wing fuel tanks were found empty. The right wing was found separated from the fuselage. No evidence of fuel was noted in the right wing fuel tanks, and no evidence of fuel leakage was found at the accident site. The pilot reported that he saw fuel leaking out of the right wing fuel vent after the accident; it is possible that a small quantity of the airplane’s unusable fuel for the right tank could have leaked out immediately after the accident. Although the pilot believed that the airplane had enough fuel onboard for the flight, his assessment was based on his calculations of the airplane’s fuel burn during several short flights he made after having the airplane topped off with fuel the night before the accident; he did not visually check the fuel level in the tanks before departing on the accident flight. The lack of fuel in the fuel tanks, the lack of evidence of fuel leakage, the loss of engine power in both engines, and the lack of mechanical anomalies are consistent with fuel exhaustion.

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.

The twin engine aircraft departed Bogotá-El Dorado Airport at 0600LT on an ambulance flight to Araracuara, State of Caquetá, carrying two doctors, one patient and two pilots. Fifteen minutes into the flight, the crew contacted ATC, reported problems and was cleared to divert to Villavicencio. On approach to Villavicencio-La Vanguardia Airport, the aircraft stalled and crashed in a wooded area parallel to a road, bursting into flames. The aircraft was destroyed by a post crash fire and all five occupants were killed.

Following an uneventful flight from Thompson, the crew completed the approach and landing at Churchill Airport. After touchdown, the crew started the braking procedure and was vacating the runway when the right main gear collapsed. This caused the right propeller and the right wing to struck the ground. The aircraft was stopped and all five occupants evacuated safely. The aircraft was damaged beyond repair.

The pilot stated that the flight was conducted at night and he used his GPS track to align with the runway. When the pilot activated the runway lights, the airplane was about 1/4 mile to the left of the runway and 1/2 mile from the approach end. The pilot made an aggressive right turn then hard left turn to make the runway for landing. While maneuvering on short final, at 50 feet above ground level (agl), the airplane's right wing impacted the tops of a number of trees that lined the southeast side of the runway. The airplane descended rapidly and landed hard, collapsing the landing gear and spinning the airplane around 180 degrees laterally, where it came to rest against some trees. The right wing's impact with trees and the hard landing resulted in substantial damage. The pilot reported no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.

The airplane departed during dark (moonless) night conditions over remote terrain with few ground-based light sources to provide visual cues. Weather reports indicated strong gusting wind from the northeast. According to a surviving passenger, shortly after takeoff, the pilot started a right turn; the bank angle continued to increase, and the airplane impacted terrain in a steep right bank. The accident site was about 1 mile from the airport at a location consistent with the airplane departing to the northeast and turning right about 180 degrees before ground impact. The operator's chief pilot reported that the pilot likely turned right after takeoff to fly direct to the navigational aid located southwest of the airport in order to escape the terrain induced turbulence (downdrafts) near the mountain range northeast of the airport. Examination of the airplane wreckage revealed damage and ground scars consistent with a high-energy, low-angle impact during a right turn. No evidence was found of preimpact mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot became spatially disoriented during the right turn. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the departure. This increased the importance for the pilot to monitor the airplane's flight instruments to maintain awareness of its attitude and altitude. During the turn, the pilot was likely performing the additional task of engaging the autopilot, which was located on the center console below the throttle quadrant. The combination of conducting a turn with few visual references in gusting wind conditions while engaging the autopilot left the pilot vulnerable to visual and vestibular illusions and reduced his awareness of the airplane's attitude, altitude, and trajectory. Based on toxicology findings, the pilot most likely had symptoms of an upper respiratory infection but the investigation was unable to determine what effects these symptoms may have had on his performance. A therapeutic level of doxylamine, a sedating antihistamine, was detected, and impairment by doxylamine most likely contributed to the development of spatial disorientation.