Crash of a Beechcraft 300LW Super King Air on Piz Sarsura: 2 killed

Date & Time: Feb 14, 2002 at 1720 LT
Operator:
Registration:
D-ICBC
Flight Phase:
Survivors:
No
Site:
Schedule:
Poznań – Samedan
MSN:
FA-227
YOM:
1993
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4158
Captain / Total hours on type:
1835.00
Aircraft flight hours:
4141
Circumstances:
D-ICBC was refuelled in Poznan to its maximum capacity of 2040 litres. An ATC flight plan was filed for an IFR flight. After the RENTA waypoint, VFR had actually been entered, but the crew had not filed the flight plan as a Y flight plan, as is prescribed for flights which begin under IFR rules and then end as a VFR flight. However, the flight plan was entered and transmitted as a Y flight plan by the competent unit in Brussels. Take-off time was scheduled for 14:20 UTC. Take-off actually took place at 14:35 UTC. No details are known about the history of the first part of the flight. The aircraft reached the border with Italian airspace in the planned air corridor M736 at flight level 250. The crew reported at 15:54:14 UTC to Padua ACC, sector LOW NORD on frequency 125.900 MHz: “..ua Buongiorno D-ICBC, Flight level 250, appro…approaching LIZUM Point” The air traffic controller instructed the crew to fly “LIZUM, LUSIL direct”. The crew confirmed “LIZUM .... direct DBC”. On enquiring, they received the information that they would be able to descend in about 10 miles. On the radar plot it can be seen that the aircraft did not fly as required direction LUSIL, but turned onto a heading of approximately 240° and was flying in the direction of Samedan. At 15:59:18 UTC, the clearance to flight level 170 was given; which is the lowest IFR flight level (minimum enroute altitude – MEA) in this area. At 16:02:03 UTC, the crew of D-ICBC was asked whether they were flying direct to Samedan. This was confirmed by them. They were then requested to report as soon as they wished to change from instrument flight rules to visual flight rules. At 16:05:16 UTC, the crew change from instrument flight rules to visual flight rules and were requested to contact Samedan Tower on frequency 135.325 MHz, which they did after a brief delay. The Samedan air traffic controller informed the crew that runway 21 was in use and that the QNH was 1012 hPa. He additionally requested them to report as soon as they flew into the valley. After leaving flight level 170, the aircraft turned slightly to the right onto a course of approximately 265° and maintained its continuous descent. At 16:11:25 UTC, the aircraft passed flight level 130 and began to turn slowly to the left. This turn brought the aircraft precisely onto the extended centre line of runway 21 in Samedan. The aircraft was last captured by the radar at 16:15:24. The last flight level indicated on the secondary radar was FL 101. A little later, the aircraft collided with the elevated terrain of the Sarsura glacier at an elevation of 9640 ft AMSL. Both pilots were killed immediately. The aircraft was destroyed.
Probable cause:
The accident is caused by the fact that the crew on its approach according to visual flight rules to Samedan aerodrome, under critical weather conditions and applying inappropriate flying tactics lost the situational awareness and theby the aircraft D-ICBC collided with the terrain.
The following findings were identified:
- The pilot was in possession of a senior commercial pilots licence, issued by the Polish authorities.
- There are no indications of any health problems affecting the pilot during the flight involved in the accident.
- The aircraft was admitted for traffic.
- The investigation produced no indications of any pre-existing technical faults which might have caused the accident.
- The mass and centre of gravity at the time of the accident were within the prescribed limits.
- As weather information, only METAR and TAF for Innsbruck, Zurich, Milan Malpensa and Milan Linate were found.
- No documentation for visual approaches to Samedan were found in the aircraft.
- In the documentation which was available to the investigators, it was not evident that any of the crew members had previously flown to Samedan.
Final Report:

Crash of a Lockheed MC-130P Hercules in the Hindu Kush Mountain Range

Date & Time: Feb 13, 2002 at 0230 LT
Type of aircraft:
Operator:
Registration:
66-0213
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
MSN:
4163
YOM:
1966
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On a mission for Special Forces, the four engine aircraft crashed in unknown circumstances in a snow covered area of the Hindu Kush Mountain Range, Afghanistan. All eight occupants were rescued while the aircraft was destroyed. USAF confirmed that the accident was not caused by hostile action.

Crash of a Tupolev TU-154M near Khorramabad: 119 killed

Date & Time: Feb 12, 2002 at 0755 LT
Type of aircraft:
Operator:
Registration:
EP-MBS
Survivors:
No
Site:
Schedule:
Tehran - Khorramabad
MSN:
91A871
YOM:
1991
Flight number:
IRB956
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
107
Pax fatalities:
Other fatalities:
Total fatalities:
119
Aircraft flight hours:
12701
Aircraft flight cycles:
5516
Circumstances:
Following an uneventful flight from Tehran, the crew started the descent to Khorramabad Airport runway 11 in bad weather conditions. In poor visibility, the crew failed to realize he was off course when the aircraft struck the slope of a mountain located few km northeast from the city of Sarab-e Dowreh, about 25 km northwest from the runway 11 threshold. The wreckage was found few hours later on a snow covered rock wall. The aircraft disintegrated on impact and all 119 occupants were killed, among them four Spanish citizens.
Probable cause:
Controlled flight into terrain after the crew failed to follow the approach procedures and the company SOP's. This caused the aircraft to deviate from the approach path by 3 nm to the north when it struck the mountain that was shrouded in clouds. The lack of visibility due to poor weather conditions was a contributing factor.

Crash of an Antonov AN-12BP near Agadir: 8 killed

Date & Time: Feb 7, 2002 at 0015 LT
Type of aircraft:
Operator:
Registration:
UR-LIP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Dakar – Agadir – Algiers – Athens
MSN:
9 3 464 05
YOM:
1969
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The aircraft was completing a cargo flight from Dakar to Athens with intermediate stops in Agadir and Algiers, carrying a load of fish and eight crew members. While cruising by night at an altitude of 9,900 feet in marginal weather conditions, the aircraft struck the slope of a mountain located 80 km northeast of Agadir. All eight occupants were killed.

Crash of a Boeing 727-134 on Mt El Cumbal: 94 killed

Date & Time: Jan 28, 2002 at 1024 LT
Type of aircraft:
Operator:
Registration:
HC-BLF
Flight Phase:
Survivors:
No
Site:
Schedule:
Quito - Tulcán - Cali
MSN:
19692
YOM:
1967
Flight number:
EQ120
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
87
Pax fatalities:
Other fatalities:
Total fatalities:
94
Captain / Total flying hours:
12091
Captain / Total hours on type:
8263.00
Copilot / Total flying hours:
7058
Copilot / Total hours on type:
3457
Aircraft flight hours:
64001
Aircraft flight cycles:
49819
Circumstances:
The aircraft departed Quito-Mariscal Sucre Airport runway 17 at 1001LT on a flight to Cali with an intermediate stop in Tulcán, carrying 87 passengers and 7 crew members. The flight was completed at an altitude of 18,000 feet on airway G-675 towards Ipiales, south Colombia. At a distance of 29 NM from Tulcán, the crew was cleared to descend to 14,000 feet and was briefed about the last weather conditions at destination. For unknown reasons, the crew failed to comply with the company SOP's and started the descent at an excessive speed of 230 knots while the approach procedure called for a speed of 180 knots. Also, the crew was not following the proper approach track for the Tulcán-Teniente Coronel Luis A. Mantilla Airport. In poor visibility due to clouds, at an altitude of 14,700 feet, the aircraft struck the slope of Mt El Cumbal located about 30 km northwest of Ipiales. The aircraft disintegrated on impact and all 94 occupants were killed. The wreckage was found 1,400 feet below the summit.
Probable cause:
The probable cause was:
- The decision of the instructor captain and his crew to initiate and continue the operation towards Tulcán Airport below minima weather conditions as established in the company's SOPs.
- Inadequate navigation and operation of the aircraft by the pilot-in-command and directed by the instructor captain, consisting of entering the holding pattern of the Tulcán radio beacon with a speed of 230 knots (IAS) and with a banking of 15° exceeding the maximum stipulated speed limit of 180 knots during the entire procedure including the holding pattern and using a banking below the recommended range of 25° to 30°, thus exceeding the lateral navigation and obstacle protection limits of the holding pattern, leading this operation to the collision with Mt El Cumbal.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) in Chittenden: 2 killed

Date & Time: Jan 25, 2002 at 1710 LT
Registration:
N104CS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Johnstown – Rutland
MSN:
61-0404-141
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1000
Captain / Total hours on type:
250.00
Aircraft flight hours:
1780
Circumstances:
The airplane collided with mountainous terrain during approach to the destination airport. While approaching the airport, the pilot requested vectors for a localizer approach to runway 19. Due to traffic, air traffic control (ATC) issued the pilot a holding clearance. The airplane was approaching the holding fix about 8,000 feet, when the pilot advised ATC that the airplane was picking up a little ice. ATC initially offered an amended clearance of 9,000 feet, but the pilot declined. Subsequently, he accepted the clearance and climbed back to 9,000 feet. ATC then told the pilot that after one more airplane had landed, he would be issued an approach clearance. The airplane was about 9,200 feet when the pilot replied "thank you." Review of radar data revealed that the accident airplane made one complete 360-degree turn, and one 270-degree turn on the non-holding side of the published holding pattern. During the two turns, the airplane descended to approximately 8,400 feet, climbed to 8,900 feet, then descended again to 8,300 feet. The two turns were tighter than the expected standard 2-minute turns in a holding pattern, with radii ranging from 0.3 to 0.4 nautical miles and 0.1 to 0.2 nautical miles respectively. Following the two holding turns, no more radio transmissions or radar returns were received by ATC. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Another pilot flying in the area reported moderate rime ice at 8,000 feet, but added that he climbed out of the ice and was between cloud layers at 9,000 to 10,000 feet.
Probable cause:
The pilot's failure to maintain aircraft control while holding.
Final Report:

Crash of a Cessna 207 Skywagon in Milford Sound: 6 killed

Date & Time: Jan 19, 2002 at 1000 LT
Operator:
Registration:
ZK-SEV
Flight Phase:
Survivors:
No
Site:
Schedule:
Te Anau - Milford Sound
MSN:
207-0204
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
635
Captain / Total hours on type:
13.00
Circumstances:
On Saturday, 19 January 2002, at 0931, ZK-SEV, a Cessna 207, took off from Te Anau Aerodrome for Milford Sound Aerodrome. At about 1000 the aircraft collided with the side of a mountainous valley, approximately 4400 feet above sea level and 500 metres southeast of Gertrude Saddle, some 11 kilometres from Milford Sound. The pilot and 5 passengers on board died in the collision. The aircraft probably had not reached a suitable altitude to safely cross over Gertrude Saddle, and the pilot probably left his decision too late to turn back in the valley in order to gain more height.
Probable cause:
Findings:
Findings and safety recommendations are listed in order of development and not in order of priority.
- The pilot was appropriately qualified, fit and authorised to conduct the flight.
- The aircraft records indicated the aircraft was properly maintained and airworthy. The aircraft was appropriate for the purpose and was approved for air transport operations.
- The weather conditions were suitable for the flight.
- The aircraft was probably too low to safely cross Gertrude Saddle, and the pilot probably elected to use his escape option of a left reverse turn after recognising that he would be unable to safely cross the saddle. This was left too late to safely complete the manoeuvre.
- Had the aircraft reached a suitable height to safely cross Gertrude Saddle prior to entering Gertrude Valley, the accident may have been averted.
- The pilot may have misjudged the strength of the tailwind and thus the aircraft ground speed, and the strength of any downdraughts, as he approached Gertrude Saddle. Consequently, the
closing speed with the saddle and the low height of the aircraft may have caught the pilot by surprise.
- The pilot’s delayed action in initiating a reverse turn away from Gertrude Saddle was probably a prime contributing factor to the accident.
- Pilot inexperience may have contributed to the accident.
- The current aeroplane pilot training requirements are not sufficient to ensure pilots are suitably equipped to handle the demanding flying challenges that mountainous environments can present.
Final Report:

Crash of a Fairchild-Hiller FH-227C on Mt El Tigre: 26 killed

Date & Time: Jan 17, 2002 at 1101 LT
Type of aircraft:
Operator:
Registration:
HC-AYM
Flight Phase:
Survivors:
No
Site:
Schedule:
Quito – Nueva Loja
MSN:
511
YOM:
1966
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
26
Captain / Total flying hours:
17709
Captain / Total hours on type:
8338.00
Copilot / Total flying hours:
12229
Copilot / Total hours on type:
6066
Aircraft flight hours:
29154
Aircraft flight cycles:
45178
Circumstances:
The twin engine aircraft departed Quito-Mariscal Sucre Airport at 1038LT on a charter flight to Nueva Loja-Lago Agrio Airport, carrying 21 oil workers and and five crew members on behalf of the Texaco Oil Company. While cruising under VFR mode at an altitude of 15,500 feet, the crew was instructed by ATC to change heading to 094° in order to descent to Nueva Loja for a landing on runway 23. But the crew failed to comply with this instruction and continued straight ahead. Few minutes later, the crew started the descent in foggy conditions when the aircraft struck the slope of Mt El Tigre located in the south part of Colombia, near the border with Ecuador. The wreckage was found three days later at an altitude of 4,500 metres. The aircraft disintegrated on impact and all 26 occupants were killed.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the crew suffered a loss of situational awareness since their attention was focused on aspects that were not related to the flight being executed and therefore neglecting the primary function of flight which is the control of the aircraft and decision making.
The following contributing factors were identified:
- The crew failed to maintain a sterile cockpit situation,
- The crew was continuously distracted during the flight,
- Lack of technical documentation in the CIA that supports the operation,
- Lack of crew training about Crew Resources Management, human factors and Control Flight Into Terrain(CFIT),
- The weather conditions at the time of the accident on Mt El Tigre made it impossible for the crew to see the mountain,
- The aircraft was not equipped with a Ground Proximity Warning System (GPWS).
Final Report:

Crash of an Embraer EMB-120RT Brasília in Zaldíbar: 3 killed

Date & Time: Jan 14, 2002 at 0728 LT
Type of aircraft:
Operator:
Registration:
EC-GTJ
Flight Type:
Survivors:
No
Site:
Schedule:
Madrid - Bilbao
MSN:
120-024
YOM:
1986
Flight number:
IBT1278
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7500
Captain / Total hours on type:
1575.00
Copilot / Total flying hours:
2648
Copilot / Total hours on type:
832
Aircraft flight hours:
23578
Aircraft flight cycles:
29468
Circumstances:
The twin engine airplane departed Madrid-Barajas at 0635LT on a cargo service (flight IBT1278) to Bilbao, carrying one company mechanic, two pilots and a load of cargo consisting of 2,873 kilos of various goods. Following an uneventful flight, the crew was cleared to start the descent to Bilbao-Sondica Airport for an ILS approach to runway 30. During the descent, the crew encountered control problems which he attributed to an autopilot malfunction. While trying to identify the problem, the crew failed to realized that the rate of descent increased when the GPWS alarm sounded three times. Shortly later, while attempting to gain height, the aircraft struck the slope of Mt Santa Marina Vieja located 33 km from Bilbao Airport. The aircraft was destroyed by impact forces and all three occupants were killed. The wreckage was found near the village of Zaldíbar.
Probable cause:
Controlled flight into terrain after the crew failed to maintain an adequate separation with the ground because his attention was focused on the disconnection of the autopilot system. It was also determined that the crew failed to comply with the Standard Operating Procedures published by the operator.
Final Report:

Crash of a Lockheed KC-130R Hercules at Shamsi AFB: 7 killed

Date & Time: Jan 9, 2002
Type of aircraft:
Operator:
Registration:
160021
Flight Type:
Survivors:
No
Site:
Schedule:
Jacobabad – Shamsi
MSN:
4702
YOM:
1976
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Following an uneventful flight from Jacobabad, the crew started a night approach to Shamsi AFB. While descending in limited visibility at the altitude of 3,200 feet, the four engine aircraft struck the slope of a mountain located few km from the airfield. All seven occupants were killed.
Probable cause:
It is believed that the crew lost his orientation while approaching Shamsi AFB by night and without any visual references on ground.