Crash of a Boeing 737-2H4 in Caracas

Date & Time: Oct 16, 2008 at 1530 LT
Type of aircraft:
Operator:
Registration:
YV162T
Survivors:
Yes
Schedule:
Puerto Ordaz – Caracas
MSN:
23055/970
YOM:
1983
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 28R at Caracas-Maiquetía-Simón Bolívar Airport, the aircraft deviated to the left. It eventually veered off runway to the left and went down a slope, coming to rest with its nose gear torn off. All 54 occupants evacuated safely and aircraft was damaged beyond repair.

Crash of a Boeing 737-291 near Toacaso: 3 killed

Date & Time: Aug 30, 2008 at 2103 LT
Type of aircraft:
Operator:
Registration:
YV102T
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Caracas – Latacunga
MSN:
21545/525
YOM:
1978
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9018
Captain / Total hours on type:
5915.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
989
Aircraft flight hours:
60117
Aircraft flight cycles:
52091
Circumstances:
The aircraft was parked at Caracas Airport for a while and had just been sold to an Ecuadorian operator. A crew of three departed Caracas-Maiquetía-Simón Bolívar Airport in the evening on a delivery flight to Latacunga, Ecuador. After being cleared to descend to FL180, FL150 then FL130, the crew was flying over a mountainous area when the GPWS alarm sounded. The crew apparently elected to gain height but the alarm sounded for 22 seconds when the aircraft collided with the Iliniza Volcano. The aircraft disintegrated on impact and all three occupants were killed. The wreckage was found the following day at an altitude of 3,992 metres.
Probable cause:
Non-compliance by the crew of the technical procedures, configuration, speed and bank angle of the aircraft required for the completion of the initial turn of the Instrument Approach Procedure n°4 published in the AIP Ecuador, to Latacunga Airport, a failure that placed the aircraft outside of the protected area (published pattern), leading to high elevation mountainous terrain.
Contributing factors:
- Ignorance of the crew of the area which was under the approach path.
- Lack of documentation and procedures of the airline that govern the conduct of flights to non-scheduled and special airports.

Crash of a Boeing 737-2H6 in Jambi: 1 killed

Date & Time: Aug 27, 2008 at 1634 LT
Type of aircraft:
Operator:
Registration:
PK-CJG
Survivors:
Yes
Schedule:
Jakarta - Jambi
MSN:
23320/1120
YOM:
1985
Flight number:
SJY062
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
7794
Captain / Total hours on type:
6238.00
Copilot / Total flying hours:
5254
Copilot / Total hours on type:
4143
Aircraft flight hours:
49996
Aircraft flight cycles:
54687
Circumstances:
On 27 August 2008, a Boeing 737-200 aircraft, registered PK-CJG, was being operated on a scheduled passenger service from Soekarno-Hatta International Airport, Jakarta to Sultan Thaha Airport, Jambi with flight number SJY062. On board the flight were two pilots, four flight attendants, and 124 passengers. The Pilot in Command (PIC) acted as Pilot Flying (PF) while the Second in Command (SIC) acted as Pilot Monitoring (PM). The flight time from Jakarta to Jambi was estimated to be about one hour and the aircraft was dispatched with approximately 4 hours of fuel endurance. The number one electrical engine driven generator was unserviceable, as such the Auxiliary Power Unit (APU) generator was used during the flight to maintain two generators operation. Prior to descent into Jambi, the PIC conducted the crew briefing and stated a plan for Makinga straight-in approach to runway 31 with flap 40°, reviewed the go-around procedures and stated that Palembang was the alternate airport.There was no abnormality recorded nor reported until the PIC commenced the approach to Jambi. At 09:18 UTC, the SIC contacted Thaha Tower controller and reported that the aircraft was descending and passing FL160 and had been cleared by Palembang Approach control to descend to 12,000 feet. The Thaha Tower controller issued a clearance to descend to 2500 feet and advised that runway 31 was in use. The SIC asked about the weather conditions and was informed that the wind was calm, rain over the field and low cloud on final approach to runway 31. The PIC flew the aircraft direct to intercept the final approach to runway 31. While descending through 2500 feet, and about 8 miles from the VOR, the flap one degree and flap 5° were selected. Subsequently the landing gear was extended and flap 15° was selected. 13 seconds after flap 15 selection, the pilots noticed that the hydraulic system A low pressure warning light illuminated, and also the hydraulic system A quantity indicator showed zero. The PIC commanded the SIC to check the threshold speed for the existing configuration of landing, weight and with flap 15°. The SIC called out that the threshold speed was 134 kts and the PIC decided to continue with the landing. The PIC continued the approach and advised the SIC that he aimed to fly the aircraft slightly below the normal glide path in order to get more distance available for the landing roll. The aircraft touched down at 0930 UTC and during the landing roll, the PIC had difficulty selecting the thrust reversers. The PIC the applied manual braking. During the subsequent interview, the crew reported that initially they felt a deceleration then afterward a gradual loss of deceleration. The PIC reapplied the brakes and exclaimed to the SIC about the braking condition, then the SIC also applied the brakes to maximum in responding to the situation. The aircraft drifted to the right of the runway centre line about 200 meters prior to departing off the end of the runway, and stopped about 120 meters from the end of the runway 31 in a field about 6 meters below the runway level. Three farmers who were working in that area were hit by the aircraft. One was fatally injured and the other two were seriously injured. The pilots reported that, after the aircraft came to a stop, they executed the Emergency on Ground Procedure. The PIC could not put both start levers to the cut-off position, and also could not pull the engines and APU fire warning levers. The PIC also noticed that the speed brake lever did not extend. The radio communications and the interphone were also not working. The flight attendants noticed a significant impact before the aircraft stopped. They waited for any emergency command from the PIC before ordering the evacuation. However, the passengers started to evacuate the aircraft through the right over-wing exit window before commanded by the flight attendants. The flight attendants subsequently executed the evacuation procedure without command from the PIC. The left aft cabin door was blocked by the left main landing gear that had detached from the aircraft and the flight attendants were unable to open the door. The right main landing gear and both engines were also detached from the aircraft. The Airport Rescue and Fire Fighting (ARFF) come to the crash site and activated the extinguishing agent while the passengers were evacuating the aircraft. The PIC, SIC and FA1 were the last persons to evacuate the aircraft. The APU was still running after all passengers and crew evacuation completed, afterward one company engineer went to the cockpit and switched off the APU. All crew and passengers safely evacuated the aircraft. No significant property damage was reported.
Probable cause:
Contributing Factors:
- When the aircraft approach for runway 31, the Loss of Hydraulic System A occurred at approximately at 1,600 feet. At this stage, there was sufficient time for pilots to conduct a missed approach and review the procedures and determine all the consequences prior to landing the aircraft.
- The smooth touchdown with a speed 27 kts greater than Vref and the absence of speed brake selection, led to the aircraft not decelerating as expected.
Final Report:

Crash of a Boeing 737-219 in Bishkek: 65 killed

Date & Time: Aug 24, 2008 at 2044 LT
Type of aircraft:
Operator:
Registration:
EX-009
Survivors:
Yes
Schedule:
Bichkek - Tehran
MSN:
22088/676
YOM:
1980
Flight number:
IRC6895
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
85
Pax fatalities:
Other fatalities:
Total fatalities:
65
Captain / Total flying hours:
18250
Captain / Total hours on type:
2337.00
Copilot / Total flying hours:
4531
Copilot / Total hours on type:
881
Aircraft flight hours:
60014
Aircraft flight cycles:
56196
Circumstances:
On 24 August, 2008 the Boeing 737-200 aircraft registered ЕХ-009 and operated by a crew including a PIC and a Co-pilot of Itek Air was flying a scheduled passenger flight IRC 6895 from Bishkek to Tehran. Also on board there was the cabin crew (3 persons) as well as 85 passengers including two service passengers: a maintenance engineer and a representative of the Iran Aseman Airlines. Flight IRC 6895 was executed in compliance with the leasing agreement No. 023/05 of 15 July, 2005 for the Boeing 737-200 ЕХ-009 between the Kyrgyz airline, Itek Air, and the Iran Aseman Airlines. The crew passed a medical examination in the ground medical office of Manas Airport. The crew did not have any complaints of their health. The crew received a complete preflight briefing. The weather at the departure airport Manas, the destination airport and at alternate aerodromes was favourable for the flight. Total fuel was 12000 kg, the takeoff weight was 48371 kg with the CG at 24,8% MAC, which was within the B737-200 AFM limitations. After the climb to approximately 3000 m the crew informed the ATC about a pressurization system fault and decided to return to the aerodrome of departure. While they were descending for visual approach the aircraft collided with the ground, was damaged on impact and burnt. As a result of the crash and the following ground fire 64 passengers died. The passenger who was transferred on 29 August, 2008 to the burn resuscitation department of the Moscow Sklifasovsky Research Institute died of burn disease complicated by pneumonia on 23 October, 2008, two months after he got burn injuries. Thus, his death is connected with the injuries received due to the accident.
Probable cause:
The cause of the Itek Air B737-200 ЕХ-009 accident during the air-turn back due to the cabin not pressurizing (probably caused by the jamming of the left forward door seal) was that the crew allowed the aircraft to descend at night to a lower than the minimum descent altitude for visual approach which resulted in the crash with damage to the aircraft followed by the fire and fatalities. The combination of the following factors contributed to the accident:
- Deviations from the Boeing 737-200 SOP and PF/PM task sharing principles;
- Non-adherence to visual approach rules, as the crew did not keep visual contact with the runway and/or ground references and did not follow the prescribed procedures after they lost visual contact;
- Loss of altitude control during the missed approach (which was performed because the PIC incorrectly evaluated the aircraft position in comparison with the required descent flight path when he decided to perform visual straight-in approach);
- Non-adherence to the prescribed procedures after the TAWS warning was triggered.
Final Report:

Crash of a Boeing 737-282 in Port Harcourt

Date & Time: Jul 14, 2008 at 1844 LT
Type of aircraft:
Operator:
Registration:
5N-BIG
Survivors:
Yes
Schedule:
Lagos – Port Harcourt
MSN:
23044/973
YOM:
1983
Flight number:
NCH138
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8688
Captain / Total hours on type:
452.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
2500
Aircraft flight hours:
55508
Aircraft flight cycles:
36263
Circumstances:
On 14th July, 2008 at 16:49 h, a Boeing 737–282 aircraft with nationality and registration marks 5N-BIG, operated by Chanchangi Airlines Ltd, commenced a scheduled domestic flight from Murtala Muhammed International Airport, (DNMM) with call sign NCH138 for Port Harcourt International Airport (DNPO). Instrument Flight Rules (IFR) flight plan was filed for the flight. There were 47 persons on board (41 passengers, 2 flight crew and 4 flight attendants) and 3 hours fuel endurance. The Captain was the Pilot Flying (PF) and The First Officer (FO) was the Pilot Monitoring (PM). The FO stated that NCH138 was initially scheduled to depart at 15:30 h, but the flight was delayed due to loading of passenger baggage. The Captain stated that NCH138 was cleared to FL290 and the flight continued normally. According to the DNPO Air Traffic Control (ATC) watch supervisor on duty, NCH138 contacted DNPO Approach Control (APP) at 17:05 h with flight information estimating POT at 17:50 h. NCH138 was issued an inbound clearance to POT1 VOR2 with the following weather information for 17:00 h as: Wind calm, Visibility 10 km, Broken clouds 270 m, Scattered clouds 600 m, Cumulonimbus clouds scattered, temperature 25/24°C, Thunderstorms, Temporarily Variable 8 kt, gusting 18 kt, Visibility 3000 m, Thunderstorms and rain, and expect runway (RWY) 21 for landing. According to the First Officer NCH138 requested descent into POT at about 100 NM. The Captain added that due to ATC delay, the descent commenced at about 80 NM. The Control Tower Watch Supervisor stated that at 18:00 h, NCH138 requested to hold over POT at 3500 ft for weather improvement, because there was rain overhead the station with build-up closing in at the threshold of RWY 21. At about 15 NM, between radials 180° and 210°, NCH138 reported breaking out of weather. At 18:19 h, NCH138 requested weather information from the Tower. Tower advised the flight crew that RWY 03 was better for landing. At this time, NCH138 requested RWY 03 for approach and Approach Control cleared NCH138 for the approach to RWY 03. At 18:27 h, the flight crew reported established on approach to RWY 03, leaving 2000 ft. The Approach Control then transferred NCH138 to DNPO Tower for landing instructions. At 18:28 h, the Tower instructed NCH138 to report field in sight. The flight crew acknowledged and reported RWY 03 in sight. Tower cleared NCH138 to land on RWY 03 and NCH138 was cautioned that the runway was wet. At 18:34 h, NCH138 executed and reported a missed approach. NCH138 requested a climb to 3500 ft. NCH138 was cleared to climb and instructed to report overhead POT. At 18:39 h, NCH138 requested a descent and clearance for an approach to RWY 21. Approach Control cleared NCH138 to descend to 2000 ft and report to Tower when established on the approach and also to report leaving 2000 ft. At 18:42 h, NCH138 reported inbound maintaining 2000 ft. The Approach Control requested the distance from the runway and sought consent of NCH138 for Arik 514 at the holding point to take off. NCH138 declined, as they were about 10 miles to touchdown. At 18:45 h, NCH138 reported five miles to touchdown. Approach Control acknowledged and instructed NCH138 to report field in sight and thereafter handed over to Tower on 119.2 MHz. When contacting the Tower, NCH138 was cleared to land on RWY 21, wind 0100 /10 kt and was advised to exercise caution due to wet runway. NCH138 acknowledged the clearance. NCH138 landed hard and bounced three times on the runway. According to the ATC controller, after touch down the aircraft rolled in an s-pattern before it overran the runway. NCH138 made a 180° turn with the right engine hitting the ground. The aircraft came to a final stop on the left side and 10 m beyond the stopway. The accident occurred at night in Instrument Meteorological Conditions (IMC). The Aerodrome Rescue and Fire Fighting Service (ARFFS) arrived the scene and commenced rescue operations immediately. All occupants on board were evacuated; one passenger sustaining a minor injury.
Probable cause:
The decision to land following an unstabilized approach (high rate of descent and high approach speed. A go-around was not initiated.
Contributory factors:
1. The deteriorating weather conditions with a line squall prevented a diversion to the alternates.
2. The runway was wet with significant patches of standing water.
Final Report:

Crash of a Boeing 737-230 in Malang

Date & Time: Nov 1, 2007 at 1324 LT
Type of aircraft:
Operator:
Registration:
PK-RIL
Survivors:
Yes
Schedule:
Jakarta – Malang
MSN:
22137/788
YOM:
1981
Flight number:
RI260
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
89
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19357
Captain / Total hours on type:
10667.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
1528
Aircraft flight hours:
57823
Circumstances:
On 1 November 2007, a Boeing Company B737-200 aircraft, registered PK-RIL, operated by PT. Mandala Airlines as flight number MDL 260, was on a scheduled passenger flight from Jakarta Soekarno-Hatta International Airport, Jakarta, to Abdurrachman Saleh Airport, Malang, East Java. The pilot in command (PIC) was the handling pilot, and the copilot was the support/monitoring pilot. There were 94 persons on board the aircraft, consisting of two pilots, three cabin crew, and 89 passengers. The aircraft landed at Malang at 1324 Western Indonesian Standard Time (06:24 Coordinated Universal Time (UTC). It was reported to have been raining heavily when the aircraft landed on runway 35 at Malang. The aircraft bounced twice after the initial severe hard landing, and the lower drag strut of the nose landing gear fractured, resulting in the rearwards collapse of the nose landing gear and separation of the lower nose landing gear shock strut and wheel assembly. The aircraft’s nose then contacted the runway, and the aircraft came to rest 290 metres before the departure end of runway 17. The crew subsequently reported that during the visual segment of the landing approach, they realized that the aircraft was too high with reference to the precision approach path indicator (PAPI) for runway 35. The PIC increased the aircraft’s rate of descent (ROD) to capture the PAPI. The high ROD was not arrested, and as a consequence, the severe hard landing occurred which substantially damaged the aircraft. No one of the passengers or crew was injured.
Probable cause:
The flight crew did not appear to have an awareness that the aircraft was above the desired approach path to runway 35 at Malang until they sighted the visual approach slope indication lighting system. The pilot in command continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions. Non-adherence by the flight crew to stabilized approach procedures, which resulted in the initial severe hard landing at Malang, together with the omission of a high bounced landing recovery, resulted in substantial damage to the aircraft. The following findings were identified:
- The PIC allowed the approach at Malang to become unstabilized and did not correct that condition.
- The PIC continued the approach in reduced visibility and heavy rain; marginal visual meteorological conditions.
- Neither pilot responded appropriately to the ground proximity warning system voice aural ‘SINK RATE’ or ‘PULL UP’ warnings that sounded during the final approach to Malang.
- The PIC did not initiate action to recover from the high bounced landing following the initial severe hard landing impact.
- The PIC did not ensure that effective crew coordination was maintained during the landing approach.
Final Report: