Crash of an ATR42-320 in Puerto Ordaz: 17 killed

Date & Time: Sep 13, 2010 at 1023 LT
Type of aircraft:
Operator:
Registration:
YV1010
Survivors:
Yes
Schedule:
Porlamar - Puerto Ordaz
MSN:
371
YOM:
1994
Flight number:
VCV2350
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total hours on type:
1574.00
Copilot / Total flying hours:
1083
Copilot / Total hours on type:
483
Aircraft flight hours:
27085
Aircraft flight cycles:
29603
Circumstances:
Following two uneventful flights to Santiago Mariño and Maturín, the aircraft departed Porlamar on a flight to Puerto Ordaz with 47 passengers and a crew of four on board. While descending to Puerto Ordaz, at an altitude of 13,500 feet and at a distance of 79 km from the destination, the crew reported control difficulties. After being prioritized, the crew was instructed for an approach and landing on runway 07. At 1021LT, the crew reported his position at 3,000 feet and 28 km from the destination Airport. Two minutes later, the message 'mayday mayday mayday' was heard on the frequency. The aircraft went out of control and crashed in an industrial area located about 9 km short of runway, bursting into flames. Three crew members and 14 passengers were killed while 34 other occupants were injured, 10 seriously.
Probable cause:
The most probable cause for the occurrence of the accident was the malfunction of the centralized crew warning system (CCAS/CAC) with erroneous activation of the flight loss of lift warning system.
The following contributing factors were identified:
- Poor crew resources management,
- Loss of situational awareness,
- Inadequate coordination during the decision-making process to deal with abnormal situations in flight,
- Ignorance of the loss of lift warning system.
- Inadequate handling of flight controls.
Final Report:

Crash of an ATR42-300 near Balikpapan

Date & Time: Feb 11, 2010 at 1150 LT
Type of aircraft:
Operator:
Registration:
PK-YRP
Flight Phase:
Survivors:
Yes
Schedule:
Tanjung Redep - Samarinda
MSN:
50
YOM:
1987
Flight number:
TGN162
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Copilot / Total flying hours:
2000
Aircraft flight hours:
34414
Aircraft flight cycles:
42107
Circumstances:
On 11 February 2010, an Avions de Transport Regional ATR 42-300 aircraft, registered PK-YRP, was being operated by Trigana Air Service on a scheduled passenger service between Kalimarau Airport Berau (BEJ) and Samarinda (SRI) as flight TGN162. There were 52 persons on board; two pilots, one engineer, two flight attendants, one flight dispatcher and 46 passengers (43 adults, one child, and two infants). The aircraft departed from Berau at 0230 UTC1 and climbed to Flight Level 140. Balikpapan approach cleared the crew to track from en-route Way Point LOLOT direct to Samarinda. After transferring to Temindung Tower, Samarinda, the crew was cleared to track direct to left downwind for runway 04. The controller informed them that the wind was 060/12 knots. The crew did not report any abnormalities and the aircraft operation appeared to be normal. During the final approach for runway 04, the left ECU light illuminated followed by low oil pressure and torque indications. The Pilot in Command decided to go around, divert to Balikpapan, and carry out the QRH engine shut-down procedure. They commenced the climb to 4000 ft with the left engine inoperative. Approximately 16 Nm from Balikpapan Airport, while climbing through 3,800 feet, the right ECU light illuminated, immediately followed by low oil pressure and low torque indications. The right engine then failed. The crew broadcast a MAYDAY to Balikpapan Approach and decided to conduct a forced landing into a clear field in the Samboja area, about 16 Nm from the Balikpapan Airport. The PIC gave instructions to the Flight Attendant to prepare the passengers for an emergency landing. After the aircraft came to a stop the PIC initiated an evacuation.
Probable cause:
The both engine were lack of fuel before flame out, it was indicated the fuel management was out of control during flight that might be a misleading of fuel quantity indication. The proper analysis could not be carried out due to both FDR and CVR were un-operated.
Final Report:

Crash of an ATR42-320 in Lubbock

Date & Time: Jan 27, 2009 at 0437 LT
Type of aircraft:
Operator:
Registration:
N902FX
Flight Type:
Survivors:
Yes
Schedule:
Fort Worth - Lubbock
MSN:
175
YOM:
1990
Flight number:
FX8284
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13935
Captain / Total hours on type:
2052.00
Copilot / Total flying hours:
2109
Copilot / Total hours on type:
130
Aircraft flight hours:
28768
Aircraft flight cycles:
32379
Circumstances:
Aircraft was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude.
Contributing to the accident were:
-the flight crew’s failure to follow published standard operating procedures in response to a flap anomaly,
-the captain’s decision to continue with the unstabilized approach
-the flight crew’s poor crew resource management,
-fatigue due to the time of day in which the accident occurred and a cumulative sleep debt which likely impaired the captain’s performance.
Final Report:

Crash of an ATR42-300 in Mérida: 46 killed

Date & Time: Feb 21, 2008 at 1700 LT
Type of aircraft:
Operator:
Registration:
YV1449
Flight Phase:
Survivors:
No
Site:
Schedule:
Mérida – Caracas
MSN:
28
YOM:
1986
Flight number:
BBR518
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
46
Circumstances:
After takeoff from Mérida-Alberto Carnevalli Airport runway 25, the aircraft climbed in clouds when it collided with a mountain located 10 km northwest of the airport. The aircraft disintegrated on impact and all 46 occupants were killed. The wreckage was found at an altitude of 4,100 metres.
Probable cause:
After departure from runway 25, the crew planned to use an unpublished procedure. Climbing through clouds a 180-degree turn was initiated. Using the unreliable magnetic compass, the flight made a 270 degree turn, heading towards rising terrain. The captain took over control from the copilot. When visual contact with terrain was regained, the crew noted they were heading for mountains. The captain tried to avoid rising terrain but the aircraft impacted the side of a mountain at 4,100 metres.

Crash of an ATR42-300 in São Paulo

Date & Time: Jul 16, 2007 at 1242 LT
Type of aircraft:
Operator:
Registration:
PT-MFK
Survivors:
Yes
Schedule:
Araçatuba – Bauru – São Paulo
MSN:
225
YOM:
1991
Flight number:
PTN4763
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7420
Captain / Total hours on type:
4993.00
Copilot / Total flying hours:
947
Copilot / Total hours on type:
797
Circumstances:
The aircraft departed Araçatuba on a flight to São Paulo with an intermediate stop in Bauru, carrying 21 passengers and a crew of four. After touchdown on wet runway 17R at Congonhas Airport, the crew started the braking procedure when the aircraft deviated to the left and veered off runway. While contacting soft ground, the aircraft collided with a concrete block housing the electrical device supplying the runway light system. On impact, the nose gear was torn off and the aircraft came to rest. All 25 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Loss of control upon landing after the aircraft suffered aquaplaning. The following contributing factors were identified:
- A light rain caused the presence of water on the runway, enabling the occurrence of hydroplaning.
- The accumulation of water on the surface of the runway, as a result of inadequate drainage, lack of "grooving", enabled the hydroplaning.
- The pilot applied full pressure on the right pedal, generating a force to the left that contributed to the departure off the runway.
- During hydroplaning, the pilot should not apply pedal to the opposite side to which the aircraft slides; this fact was not covered during the instruction of the pilot.
- In the face of hydroplaning, the pilot applied the right pedal, aggravating the departure of the aircraft to the left.
Final Report:

Ground accident of an ATR42-300 in Rome

Date & Time: Mar 6, 2003 at 2050 LT
Type of aircraft:
Operator:
Registration:
I-ATRF
Flight Phase:
Survivors:
Yes
Schedule:
Rome - Rimini
MSN:
034
YOM:
1986
Flight number:
MTC403
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7685
Captain / Total hours on type:
1159.00
Copilot / Total flying hours:
740
Copilot / Total hours on type:
232
Aircraft flight hours:
27472
Aircraft flight cycles:
28492
Circumstances:
Following a normal taxi procedure at Rome-Fiumicino Airport, the crew was at the holding point of runway 25, ready for departure. On board were 42 passengers and a crew of three. Both engines were turning at 70% torque. When the crew released the brakes, the swinging lever of the left main gear failed. The aircraft sank on its belly and stopped. All 45 occupants evacuated safely and there were no injuries. The aircraft was damaged beyond repair.
Probable cause:
Failure of the swinging lever of the left main gear due to the presence of fatigue cracks.
Final Report:

Crash of an ATR42-312 near Paranapanema: 2 killed

Date & Time: Sep 14, 2002 at 0540 LT
Type of aircraft:
Operator:
Registration:
PT-MTS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
São Paulo – Londrina
MSN:
026
YOM:
1986
Flight number:
TTL5561
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6627
Captain / Total hours on type:
3465.00
Copilot / Total flying hours:
2758
Copilot / Total hours on type:
1258
Aircraft flight hours:
33371
Aircraft flight cycles:
22922
Circumstances:
The twin engine airplane departed São Paulo-Guarulhos Airport at 0440LT on a postal service (flight TTL5561) to Londrina with two pilots on board. About an hour into the flight, while cruising at an altitude of 18,000 feet, the autopilot disconnected while the crew was encountering technical problems with the elevator trim system. The captain asked the copilot to pull out the circuit breaker but this instruction was not understood immediately. Nevertheless, the copilot executed this request few seconds later. Shortly later, the aircraft nosed down and the Vmo alarm sounded, indicating to the crew that the aircraft's speed was above the maximum operating speed. The crew reduced the engine power to 10% but the aircraft entered an uncontrolled descent and crashed at a speed of 366 knots in an open field located 38 km south of Paranapanema. The aircraft was totally destroyed upon impact and both pilots were killed. Some debris were found at a depth of three metres.
Probable cause:
The following findings were identified:
- The pilots' perception about the situation was affected by lack of specific training and procedures, which, coupled with the limited time available for action and lack of clarity in communications, influenced the time elapsed for taking corrective actions.
- Communication between the crew was not clear at the time of emergency, making the co-pilot did not understand at first, the action to be performed, which increased the time spent to disarm the CB. Such facts, however, can not be separated from the situation experienced by pilots with inadequate training for emergency and in a short time to identify the problem and take the corrective actions.
- The company had not provided a regular CRM training to pilots. Furthermore, the captain did not receive simulator training for over one year. It was impossible to determine, however, if the regular training and updating of the CRM simulator training of the pilot would have prevented the accident.
- The removal of the pilot from his seat at the time of the emergency may have increased the time spent in identifying the crash and taking corrective actions, but it was not possible to establish whether the accident would be avoided if he would have been in the cockpit. The copilot was slow to understand the situation and initiate corrective actions, although the alarm 'whooler' has sounded, also increasing the elapsed time.
- The operational testing under J IC 27-32-00 allowed the partial completion of the procedures due to lack of clarity, which allowed the release of the aircraft for flight with a defective relay.
Furthermore, although the elevator trim system has been certified, no procedure for emergency triggering of the compensator in the manuals provided by the manufacturer, no replacement intervals of the components of the elevator trim system in "Time Limits" systems normal and reserves were not independent and the system had a low tolerance for errors.
Final Report:

Crash of an ATR42-320 in Tel Aviv

Date & Time: Jun 18, 2001
Type of aircraft:
Operator:
Registration:
4X-ATK
Survivors:
Yes
MSN:
073
YOM:
1987
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Tel Aviv-Ben Gurion Intl Airport, the right main gear remained stuck in its wheel well. The crew informed ATC about the situation and continued the approach. After touchdown, the aircraft slid for few dozen metres then veered off runway to the right and came to rest. All 42 occupants escaped uninjured while the aircraft was damaged beyond repair.