Crash of a Dornier DO228-202K in Simikot

Date & Time: Jun 1, 2013 at 0714 LT
Type of aircraft:
Operator:
Registration:
9N-AHB
Survivors:
Yes
Schedule:
Nepalgunj - Simikot
MSN:
8169
YOM:
1989
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a charter flight from Nepalgunj to Simikot, carrying two pilots and five passengers. On approach to Simikot Airport, ground fog and low visibility forced the crew to initiate a go-around procedure. A second and a third attempt to land were abandoned few minutes later. During the fourth attempt to land, without sufficient visual contact with the ground, the crew continued the approach, passed through the clouds when the aircraft landed hard short of runway 28. Upon impact, the undercarriage were torn off and the aircraft slid for few dozen metres, veered to the right and came to rest on the right side of the runway with its left wing broken in two. All seven occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a BAe ATP in Wamena

Date & Time: May 31, 2013 at 0709 LT
Type of aircraft:
Operator:
Registration:
PK-DGI
Flight Type:
Survivors:
Yes
Schedule:
Jayapura - Wamena
MSN:
2027
YOM:
1990
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3108
Captain / Total hours on type:
1366.00
Copilot / Total flying hours:
5648
Copilot / Total hours on type:
689
Aircraft flight hours:
15755
Aircraft flight cycles:
25431
Circumstances:
On 31 May 2013 aircraft BAe ATP freighter registered PK-DGI operated by PT. Deraya as scheduled cargo/ freight flight from Sentani Airport (WAJJ) to Wamena Airport (WAJW), Papua. On board in this flight were the Pilot in Command (PIC) acted as Pilot Flying (PF) and the Second in Command (SIC) acted as Pilot Monitoring (PM). At 2127 UTC (0627 LT) the aircraft departed from Sentani Airport. The aircraft cruised at 12,000 feet (FL 120)and estimated time of arrival Wamena Airport was 2207 UTC (0707 LT). The first pilot contact with Wamena Tower controller was at 2201 UTC, the aircraft position was approaching Pass Valley point, the controller informed that runway 15 expect to be used and the weather condition was wind calm, visibility 4 Km, low cloud at final area and QNH 1008 mbs. There was no specific of approach and landing briefing by pilot flying to the pilot non flying considering to such weather condition. At 2207 UTC, the pilot reported the position was on final runway 15. The controller requested the information of the flight condition and the pilot reported that the runway has not insight. At 2209 UTC, the pilot reported that the runway was insight and the controller provided the clearance to land and 25 seconds later the aircraft touched down on the centerline. During the landing roll at about 750 meters from the beginning of runway 15 the aircraft veered to the left of the runway shoulder, the pilot recovered by applying the right rudder and asymmetry reverses thrust but the aircraft continued veer to the left and stopped at about 10 meters on the left shoulder of the runway 15. On the landing roll, the FDR recorded that the left engine torque greater then right engine torque. The pilot shutdown both engines normally and evacuated the aircraft safely. The nose landing gear detached and found on the shoulder at about 250 meter from the aircraft final position. The main landing gears broken and all the propellers bent. No injured in this occurrence.
Probable cause:
The following contributing factors were identified:
- The flight did not meet the criteria according to the recommended elements of stabilized approach which required go around.
- The aircraft touched down with 2° misalignment with the runway direction then the aircraft veered off to the left.
- The recovery action was not in accordance to the correct technique according to the ALAR Tool Kit.
Final Report:

Crash of a Boeing KC-137E Stratoliner in Port-au-Prince

Date & Time: May 26, 2013 at 1430 LT
Type of aircraft:
Operator:
Registration:
2404
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Port-au-Prince - Manaus
MSN:
19870/702
YOM:
1968
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was returning to Manaus (Ponta Pelada AFB) with a crew of 12 and 131 Brazilian soldiers who took part of the United Nations Stabilization Mission In Haiti (UNSTAMIH). During the takeoff roll on runway 28, an engine caught fire. The Captain aborted the takeoff procedure and started an emergency braking manoeuvre. The aircraft veered off runway to the left and entered a grassy area. The nose gear was torn off and the aircraft slid for several metres before coming to rest. All 143 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
An engine caught fire during takeoff for unknown reasons.

Crash of a Lockheed C-130J-30 Super Hercules at Shank AFB

Date & Time: May 19, 2013 at 1420 LT
Type of aircraft:
Operator:
Registration:
04-3144
Flight Type:
Survivors:
Yes
Schedule:
Kandahar – Shank AFB
MSN:
5560
YOM:
2004
Location:
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
904.00
Copilot / Total hours on type:
252
Circumstances:
On 19 May 2013, at approximately 0950 Zulu (1420 local), a C-130J, tail number (T/N) 04-3144, assigned to the 41st Airlift Squadron, 19th Airlift Wing, Little Rock Air Force Base (AFB), Arkansas, ran off the end of a runway at Forward Operating Base (FOB) Shank, Northeast, Afghanistan, struck a ditch which collapsed the nose gear and eventually ripped the right main landing gear from the fuselage. The right outboard engine struck the ground, pressurized fuel and oil lines were broken, fluid was sprayed over the cracked engine casing, and the right wing caught fire. The mishap aircraft (MA) came to a full stop at approximately 544 feet (ft) off the end of the paved runway surface. The mishap crew (MC), Aeromedical Evacuation (AE) crew and two ambulatory patients safely evacuated the aircraft through the top flight-deck emergency escape hatch meeting 600 ft off the nose of the aircraft. There were no fatalities, significant injuries or damage to civilian property. The total estimated loss is $73,990,265. The MA was on an AE mission and included five active duty C-130J crewmembers from the 772nd Expeditionary Airlift Squadron (19th Airlift Wing deployed), Kandahar Air Base (AB), Afghanistan. Additionally, the MA had aboard six reserve AE crewmembers from the 651st Expeditionary Aeromedical Evacuation Squadron (349th Air Mobility Wing and 433rd Airlift Wing deployed), Kandahar AB, Afghanistan. The mishap sortie happened on the third of five planned legs that day to an airfield that was at 6,809 ft Mean Sea Level (MSL) and experiencing winds varying from 200 to 250 degrees gusting from 6 to 28 knots. On the second attempted landing, the MA touched down approximately 1,500 ft down the runway but was 27 knots indicated airspeed (KIAS) faster than computed touchdown landing speed leading to the aircraft going off the end of the runway at approximately 49 KIAS.
Probable cause:
On the second landing attempt at a high altitude airfield (6,809 ft MSL), poor CRM coupled with a late power reduction by MP1 caused the MA to touchdown 27 KIAS faster than computed touchdown landing speed leading to the aircraft going off the end of the runway at approximately 49 KIAS. Because of unique aircraft performance characteristics when operating into and out of high altitude airfields, there was no way that the MA could perform a 50% flap landing (in accordance with T.O. 1C-130(C)J-1-1 landing assumptions, nose wheel landing gear speed restrictions and power level transition speed restrictions) at FOB Shank and land 27 KIAS fast. The MA’s actual landing speed simply overtasked the aircrafts capability to stop within the runway available.
Several factors substantially contributed to this mishap, including:
- Channelized attention,
- Risk assessment during operation,
- Delayed necessary action,
- Response set,
- Procedural error.
Final Report:

Crash of a Xian MA60 in Mong Hsat

Date & Time: May 16, 2013 at 1148 LT
Type of aircraft:
Operator:
Registration:
XY-AIQ
Survivors:
Yes
Schedule:
Yangon - Heho - Mong Hsat
MSN:
08 08
YOM:
2010
Flight number:
UB646
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
51
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9066
Captain / Total hours on type:
2377.00
Copilot / Total flying hours:
3414
Copilot / Total hours on type:
1871
Aircraft flight hours:
3457
Aircraft flight cycles:
2973
Circumstances:
On 16 May 2013 at 08:00 local Time, Myanma Airways MA-60 aircraft registered XY- AIQ (MSN-0808) departed Yangon International Airport (VYYY) to Monghsat Airport. For this flight captain assigned FO to line training (Command) pilot and aircraft landed to Monghsat at about 09:25 local time. After passengers disembarked and boarded, aircraft departed to Heho at 09:55 local time and landed at about 10:40 local time. Aircraft refueled at Heho and departed to Monghsat at 11:10 local time with 4 crews and 51 passengers. First officer was designated as the Pilot flying for this flight. Captain contacted to Monghsat ATC weather information, and aircraft climbed to 15000-ft with indicated airspeed 200 knots. Where reaching 40 Miles to Monghsat airfield, Captain request descent clearance and descent to 8000 ft. After passing transition level 125 Monghsat airfield, QNH setting and performed approach check. During approach to Monghsat airfield, weather was fine and visibility was 4-5 Miles (8- km). When reaching 3 Miles distance to runway 12, approach speed was 120 knots IAS. At about 11:47:59 local time, aircraft first touchdown to runway 12 with IAS 114 knots, vertical speed -288, flap 30 degree. During landing roll, aircraft over run to runway 30. At about (11:48:33) local time, aircraft struck to tree stump with IAS 40 knots and passing across to water drainage (gutter) located 110 meters from runway 30. After striking, aircraft turned to left 80 degree and came to rest. Cabin crews performed emergency evacuation, one passenger suffered serious injury, other one suffered minor injury and 53 of the occupants were survived. One passenger was serious injury ( back pain) and one passenger was minor injury (shoulder joint injury) due to accident. The left main leading gear and nose landing gear strut broken, left engine propeller blades broken, left wing tip broken and lower fuselage frame dents. The aircraft was substantially damaged.
Probable cause:
Primary Cause:
- During landing roll FO retracted PIA to GI position, its remain above Ground Idle position (36.8/ 36.6) degree. After (18) seconds flap position changed to retract and both engines torque start to increase.
- Aircraft IAS unable to rapid decelerate during crews applied braking.
Secondary Cause:
- Both crews are not initiated power lever reversing position.
- Crews need multi-crew operation.
Final Report:

Crash of a Harbin Yunsunji Y-12-II in Shenyang

Date & Time: May 16, 2013 at 1000 LT
Type of aircraft:
Operator:
Registration:
B-3801
Survivors:
Yes
Schedule:
Shenyang - Shenyang
MSN:
0006
YOM:
1986
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Shenyang-Taoxian Airport, the twin engine aircraft stalled and crashed on a road short of runway, bursting into flames. All three occupants escaped with minor injuries and the aircraft was totally destroyed by a post crash fire. The crew was returning to his base in Shenyang following a cloud seeding mission over the Liaoning Province.

Crash of a De Havilland DHC-6 Twin 300 Otter in Jomsom

Date & Time: May 16, 2013 at 0833 LT
Operator:
Registration:
9N-ABO
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
638
YOM:
1979
Flight number:
RNA555
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8451
Captain / Total hours on type:
8131.00
Copilot / Total flying hours:
1396
Copilot / Total hours on type:
1202
Aircraft flight hours:
32291
Aircraft flight cycles:
54267
Circumstances:
The Twin Otter (DHC6/300) aircraft with registration number 9N-ABO, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu to Pokhara for night stop on 15 May 2013 in order to accomplish up to 5 (five) Pokhara-Jomsom-Pokhara charter flights planned for the subsequent day on 16 May 2013. As per the programme, the aircraft completed first charter flight from Pokhara to Jomsom sector on 16 May 2013 morning after one and half hour waiting on ground due weather. For this second flight, the aircraft departed at 0225 UTC (08:10LT) from Pokhara to Jomsom in the command of Capt. Dipendra Pradhan and Mr. Suresh K.C. as co-pilot. There were 19 passengers including one infant and 3 crew members on board. The aircraft was operating under Visual Flight Rules (VFR). As per the CVR readout there was no reported difficulties and all the pre and post departure procedure and en-route portion of the flight were completed in normal manner. There was no indication of lacking of information and advice from Jomsom Tower. At first contact the co-pilot called Jomsom Tower and reported its position at PLATO (a compulsory reporting point) at 9 miles from Jomsom airport at 12500ft. AMSL. The Jomsom Tower advised runway 24 wind south westerly 08-12 KTS, QNH 1020, Temp 13 degree and advised to report downwind for runway 24.The co-pilot accepted by replying to join downwind for runway 24. There was no briefing and discussion between the two pilots regarding the tail wind at the airport. The PIC, then, took over the communication function from co-pilot and called Jomsom Tower, requesting to use runway 06 instead of runway 24, despite the advice of tower to use runway 24 to avoid tail wind effect in runway 06. Jomsom Tower repeated the wind speed to be 08-12 KTS for the runway 06, to which the PIC read back the wind and answered to have ”no problem”. As per the PIC request the Jomsom Tower designated runway 06 for landing and advised to report on final runway 06. The PIC did read back the same. The pre landing checklist was used, flaps with full fine in propeller rpm were taken and full flaps was also taken before touchdown. In the briefing of “missed approach” the PIC had answered to be “standard”. The aircraft touched down runway of Jomsom airport at 0245 UTC (08:30LT) at a distance of approximately 776 ft, far from the threshold of runway 06. After rolling 194 ft. in the runway, the aircraft left runway and entered grass area in the right side. The aircraft rolled around 705 ft in the grass area and entered the runway again. The maximum deviation from the runway edge was 19 ft. The Commission has observed that when aircraft touched down the runway, it was not heading in parallel to the runway centreline. After touchdown the aircraft rolled around 194ft on the runway, left the paved area and started rolling in the grass area in the right side. During the landing roll, when the aircraft was decelerating, the co-pilot had raised the flaps as per the existing practice of carrying out “after the landing “checks". As per the observation of passenger seated just behind the cockpit, after touchdown of the aircraft there was no communication between pilot and co-pilot. It seemed that pilot was busy in cockpit and facing problem. It was obvious that PIC was in dilemma in controlling aircraft. He added power to bring aircraft into the runway with an intention to lift up the aircraft. He did not brief anything to copilot about his intention and action. He started adding power with the intention of lifting up, but the aircraft was already losing its speed, due to extension of flaps by co-pilot without briefing to PIC and use of brakes (light or heavy, knowingly and unknowingly) simultaneously by the PIC. The accelerating aircraft with insufficient speed and lift to take off ran out of the runway 24 end, continued towards the river, hit the barbed fence and gabion wall with an initial impact and finally fell down into the edge of river. The left wing was rested in the mid of the river preventing the aircraft submerged into the river.
Probable cause:
The Accident Investigation Commission has determined the most probable cause of the accident as the inappropriate conduct of STOL procedure and landing technique carried out by the PIC, during landing phase and an endeavor to carry out take off again with no sufficient airspeed, no required lifting force and non availability of required runway length to roll. Contributory factors to the occurrence is the absence of proper CRM in terms of communication, coordination and briefing in between crew members on intention and action being taken by PIC, during pre and post landing phase.
Final Report:

Crash of a Learjet 35A in McMinville

Date & Time: May 13, 2013 at 1245 LT
Type of aircraft:
Operator:
Registration:
N22MS
Flight Type:
Survivors:
Yes
Schedule:
Grand Junction - McMinville
MSN:
209
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17563
Captain / Total hours on type:
996.00
Copilot / Total flying hours:
2553
Copilot / Total hours on type:
94
Aircraft flight hours:
15047
Circumstances:
The crew of the twinjet reported that the positioning flight after maintenance was uneventful. However, during the landing roll at their home base, the thrust reversers, steering, and braking systems did not respond. As the airplane approached the end of the runway, the pilot activated the emergency braking system; however, the airplane overran the end of the runway, coming to rest in a ditch. None of the three occupants were injured, but the airplane sustained substantial damage to both wings and the fuselage. Two squat switches provided redundancy within the airplane’s electrical system and were configured to prevent inadvertent activation of the thrust reversers and nosewheel steering during flight and to prevent the airplane from landing with the brakes already applied. Because postaccident examination revealed that the squat switch assemblies on the left and right landing gear struts were partially detached from their mounting pads such that both switches were deactivated, all of these systems were inoperative as the airplane landed. The switch assemblies were undamaged, and did not show evidence of being detached for a long period of time. The brakes and steering were working during taxi before departure, but this was most likely because either one or both of the switches were making partial contact at that time. Therefore, it was most likely that the squat switch assemblies were manipulated on purpose during maintenance in an effort to set the airplane’s systems to “air mode.” Examination of the maintenance records did not reveal any recent procedures that required setting the airplane to air mode, and all mechanics involved in the maintenance denied disabling the switches. Mechanics did, however, miss two opportunities to identify the anomaly, both during the return-to-service check and the predelivery aircraft and equipment status check. The anomaly was also missed by the airplane operator’s mechanic and flight crew who performed the preflight inspection. The airplane’s emergency braking system was independent of the squat switches and appeared to operate normally during a postaccident test. Prior to testing, it was noted that the emergency brake gauge indicated a full charge; therefore, although evidence suggests that the emergency brake handle was used, it was not activated with enough force by the pilot. The pilot later conceded this fact and further stated that he should have used the emergency braking system earlier during the landing roll. The airplane was equipped with a cockpit voice recorder (CVR), which captured the entire accident sequence. Analysis revealed that the airplane took just over 60 seconds to reach the runway end following touchdown, and, during that time, two attempts were made by the pilot to activate the thrust reversers. The pilot stated that as the airplane approached the runway end, the copilot made a third attempt to activate the thrust reversers, which increased the engine thrust, and thereby caused the airplane to accelerate. Audio captured on the CVR corroborated this statement.
Probable cause:
Failure of maintenance personnel to reattach the landing gear squat switches following maintenance, which rendered the airplane's steering, braking, and thrust reverser systems inoperative during landing. Contributing to the accident were the failure of both the maintenance facility mechanics and the airplane operator's mechanic and flight crew to identify the error during postmaintenance checks, a failure of the airplane's pilot to apply the emergency brakes in a timely manner, and the copilot's decision to attempt to engage the thrust reversers as the airplane approached the runway end despite multiple indications that they were inoperative and producing partial forward, rather than reverse, thrust.
Final Report:

Crash of a Beechcraft 300 Super King Air in Zacatecas: 6 killed

Date & Time: Apr 30, 2013 at 1221 LT
Operator:
Registration:
XC-LMV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zacatecas - Mexico City
MSN:
FA-83
YOM:
1986
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
8400
Aircraft flight hours:
7146
Aircraft flight cycles:
5756
Circumstances:
Shortly after takeoff from Zacatecas Airport Runway 20, while in initial climb, the crew informed ATC about technical problems with the left engine and attempted to return to land on runway 02. Eventually, the crew attempted an emergency landing when the aircraft crashed in a soft and dry terrain located southeast of the airport, bursting into flames, about one minute after takeoff. The aircraft was totally destroyed by a post crash fire and all six occupants were killed, among them two agents of the Federal Police and one employee of the Public Minister.
Probable cause:
Precautionary landing due to probable loss of left engine power, in soft and dry terrain, bogging down the legs of the main landing gear resulting in destruction of the aircraft. The following contributing factors were identified:
- Lack of application of CRM concepts,
- Lack of adherence to standard operating procedures.
Final Report:

Crash of a Boeing 747-428BCF at Bagram AFB: 7 killed

Date & Time: Apr 29, 2013 at 1527 LT
Type of aircraft:
Operator:
Registration:
N949CA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Camp Bastion - Bagram AFB - Dubaï
MSN:
25630/960
YOM:
1993
Flight number:
NCR102
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
6000
Captain / Total hours on type:
440.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
209
Circumstances:
The aircraft crashed shortly after takeoff from Bagram Air Base, Bagram, Afghanistan. All seven crewmembers—the captain, first officer, loadmaster, augmented captain and first officer, and two mechanics—died, and the airplane was destroyed from impact forces and postcrash fire. The 14 Code of Federal Regulations Part 121 supplemental cargo flight, which was operated under a multimodal contract with the US Transportation Command, was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates. The airplane’s cargo included five mine-resistant ambush-protected (MRAP) vehicles secured onto pallets and shoring. Two vehicles were 12-ton MRAP all-terrain vehicles (M-ATVs) and three were 18-ton Cougars. The cargo represented the first time that National Airlines had attempted to transport five MRAP vehicles. These vehicles were considered a special cargo load because they could not be placed in unit load devices (ULDs) and restrained in the airplane using the locking capabilities of the airplane’s main deck cargo handling system. Instead, the vehicles were secured to centerline-loaded floating pallets and restrained to the airplane’s main deck using tie-down straps. During takeoff, the airplane immediately climbed steeply then descended in a manner consistent with an aerodynamic stall. The National Transportation Safety Board’s (NTSB) investigation found strong evidence that at least one of the MRAP vehicles (the rear M-ATV) moved aft into the tail section of the airplane, damaging hydraulic systems and horizontal stabilizer components such that it was impossible for the flight crew to regain pitch control of the airplane. The likely reason for the aft movement of the cargo was that it was not properly restrained. National Airlines’ procedures in its cargo operations manual not only omitted required, safety-critical restraint information from the airplane manufacturer (Boeing) and the manufacturer of the main deck cargo handling system (Telair, which held a supplemental type certificate [STC] for the system) but also contained incorrect and unsafe methods for restraining cargo that cannot be contained in ULDs. The procedures did not correctly specify which components in the cargo system (such as available seat tracks) were available for use as tie-down attach points, did not define individual tie-down allowable loads, and did not describe the effect of measured strap angle on the capability of the attach fittings.
Probable cause:
The NTSB determines that the probable cause of this accident was National Airlines’ inadequate procedures for restraining special cargo loads, which resulted in the loadmaster’s
improper restraint of the cargo, which moved aft and damaged hydraulic systems No . 1 and 2 and horizontal stabilizer drive mechanism components, rendering the airplane uncontrollable. Contributing to the accident was the FAA’s inadequate oversight of National Airlines’ handling of special cargo loads.
Final Report: