Human factor

The crew departed Şirna Aerodrome around 0830LT on a local spraying mission. About 15 minutes into the flight, the crew encountered engine problems and elected to make an emergency landing. He found a suitable terrain and attempted to land when the aircraft collided with a small concrete wall and some bushes before coming to rest in an open field. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

On 20th April, 2012, M/s Bhoja Air Boeing 737-236A Reg # AP-BKC was scheduled to fly domestic Flight BHO-213 from Jinnah International Airport (JIAP) Karachi to Benazir Bhutto International Airport (BBIAP) Islamabad. The aircraft had 127 souls onboard including 06 flight crew members. The Mishap Aircraft (MA) took off for Islamabad at 1705 hrs Pakistan Standard Time (PST) from Karachi. The reported weather at Islamabad was thunderstorm with gusty winds. During approach for landing at BBIAP, Islamabad (OPRN), Flight BHO-213 was cleared by Islamabad Approach Radar for an Instrument Landing System (ILS) approach for Runway 30. The MA, while established on ILS (aligned with Runway 30 at prescribed altitude), at 6 miles to touchdown was asked by the Approach Radar to change over to Air Traffic Control (ATC) Tower frequency for final landing clearance. The cockpit crew came on ATC Tower frequency and flight was cleared to land at BBIAP, Islamabad, but the cockpit crew did not respond to the landing clearance call. The ATC Tower repeated the clearance but there was no response. After a few minutes, a call from a local resident was received in ATC Tower, stating that an aircraft had crashed close to Hussain Abad (A population around 4 nm short of runway 30 BBIAP, Islamabad). It was later confirmed that Flight BHO-213 had crashed and all 127 souls onboard (121 passengers + 6 flight crew) had sustained fatal injuries along with complete destruction of aircraft.

The pilot, sole aboard, was completing a local flight from Jundiaí-Comandante Rolim Adolfo Amaro Airport. Shortly after takeoff from runway 36, the pilot reported to ATC that the engine lost power and that he was not able to maintain a safe altitude. He was cleared for an immediate return and completed a circuit. On final approach to runway 18, he lost control of the airplane that crashed 180 metres short of runway and came to rest upside down, bursting into flames. The aircraft was totally destroyed and the pilot was killed.

According to a statement provided by the Jacksonville Center air traffic control (ATC) facility, the pilot contacted ATC while at flight level 270. About 25 minutes later, the airplane began to deviate from the ATC-assigned altitude and route. The controller’s attempts to contact the pilot were unsuccessful. The North American Aerospace Defense Command launched military fighter aircraft to intercept the airplane. The military pilots reported that the airplane was circling in a left turn at a high altitude and low airspeed and that its windows were partially frosted over. They also reported that the pilot was slumped over in the cockpit and not moving. They fired flares, and the pilot continued to be unresponsive. The airplane circled for about 3 hours before it descended into the Gulf of Mexico and sank. The pilot and airplane were not recovered. Review of the pilot’s Federal Aviation Administration medical records did not reveal any recent medical conditions that would have deemed him unfit to fly.

Witnesses observed the airplane depart the airport to the north and make an abrupt right turn at an altitude of about 150 feet. One witness, who was also a pilot, described the wings as “shimmying,” appearing as if the airplane stalled before it banked to the right in a nose-down attitude. The airplane crashed and was nearly consumed during the postcrash fire. A postaccident examination was conducted with no preimpact mechanical anomalies noted. Records indicate that the pilot built the airplane from a kit about 6 years before the accident. The pilot and airplane logbooks were not located during the investigation; therefore, the maintenance history for the airplane, and the pilot’s recent (and total) flight experience could not be determined. Postaccident toxicological testing revealed metabolites of the drug diazepam (Valium) in the pilot’s blood and urine. Valium is a prescription benzodiazepine classed as a central nervous system depressant and tranquilizer, used as a sleep aid and to inhibit anxiety. The amount noted in the pilot’s blood suggested he took the drug 12 to 24 hours before the accident, and, as a result, it would not have affected his performance.

On April 3, 2012, about 0920 atlantic standard time (ast), a Hawker Beechcraft C90GTx, N8116L, operated by Lider Taxi Aereo, was substantially damaged after ditching in the waters of the Caribbean Sea, 17 miles north of Aruba, following a dual loss of engine power during cruise. The flight departed Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida, and was destined for Hato International Airport (TNCC), Willemstad, Curacao. The airline transport pilot and the pilot rated passenger were uninjured. Visual meteorological conditions prevailed, and an instrument flight plan was filed for the delivery flight conducted under 14 Code of Federal Regulations Part 91. The Amsterdam arrived at the ditching location at 1120. The airplane was partially submerged. The crew of the Amsterdam attempted to prevent the airplane from sinking by placing a cable around it and hoisting it onboard. However during the attempted recovery, the fuselage broke in half and the airplane sank.

On 01.04.2012 the the UTAir Air Division 1 crew (based at Surgut AP) was conducting a scheduled passenger flight UTA-119 on the АТR 72-201 VP-BYZ A/C from Surgut to Tyumen. The landing at Tyumen (Roschino) AP was performed at 17:41 (23:41 local time). Descending for landing at Roschino (Tyumen) AD was conducted in extended cloudiness with icing conditions. According to the FDR records, the flight crew used the aircraft ice protection system. At the time of flight UTA-119 landing at Roschino (Tyumen) AD the weather was as follows: surface wind 090°-7 m/s, visibility 1600 m, showers of moderate snow with rain, significant cumulonimbus (5-7 oct.) clouds, fractonimbus, cloud base at 140 m, temperature + 0.2°C, dew point + 0.2°C, QFE 735 mmhg (980 hPa), friction coefficient 0.6; moderate icing at cloud layer from 140 m to 4800 m. Forecast for landing: tempo visibility 500 m, showers of heavy snow with rain, vertical visibility 90 m. Weather at Roschino (Tyumen) AD at day time on 01.04.2012 and at night from 01.04.2012 to 02.04.2012 was formed by the cyclone trough forward part with the widespread precipitation area associated with warm front. A passage of the warm front through Roschino (Tyumen) AD was expected in the period from 20:00 to 21:00, with a temperature of 0°C and relative humidity 100% precipitations were fallen from the cumulonimbus and fractonimbus clouds in form of showers of snow with rain. Visibility in precipitations was 1200–1600 m with individual charges of heavy wet snow with visibility 600–700 m and vertical visibility 100 m. Precipitation was followed by east wind 9–10 m/s, direction 90–110°, with individual gusts up to 13–14 m/s. This direction of wind remained till 21:00. After the passage of front through the region of Roschino (Tyumen) AD, at 21:05 the surface wind changed its direction to the west 250° – 260° with gradual increase of wind speed from 2–4 m/s to 7–10 m/s. Precipitation in the form of showers of moderate snow with rain at Roschino (Tyumen) AD went on till 22:00, 01.04.2012. From 22:00, 01.04.2012 to 01:00, 02.04.2012 precipitation turned into showers of slight snow with rain with a temperature of 0°C and relative humidity 100%. According to the observations of weather stations situated at a distance of about 200– 250 km from Roschino (Tyumen) AD and affected by the cyclone on 01.04.2012 as well as on 02.04.2012 storm detecting information was sent to the Roschino (Tyumen) AD AMC about glaze-ice accretion of wet snow. After the landing the A/C was placed at stand 3 heading to the air terminal (MH 30°). According to the flight shift work schedule, the crew left for rest to the Liner Hotel at Roschino AP and had a rest till 23:30 (05:30 local time). After having their rest, the crew members arrived to the AP and started the preflight preparation for the UTA120 scheduled passenger flight from Tyumen to Surgut with visiting AMC where at 00:15 they got weather briefing and documentation. The Nizhnevartovsk AD had been appointed as the alternate AP. At the end of the weather briefing the PIC received Form АВ-11 No.1 and put his signature at the sheet of the "Log of flight crews’ weather briefings at Tyumen-Roschino AMC" indicating the flight number and the A/C number. The weather forecast and actual weather at the departure AD, destination AD and alternate AD as well as their technical conditions did not imply any hazard for the flight operation. At 00:20 the crew passed a medical examination at the AP pre-start medical station and was cleared for the flight. According to the intra-airport radio conversation, around the same time the PIC made his decision to fly. After the medical examination, the F/O visited the aeronautical information office and received a navigator’s briefcase and flight plan; which is recorded in pertinent logbooks. Further, the crew continued the preflight preparation in the briefing room. According to the load documents there were 39 passengers, 133 kg of cargo, 143 kg of passengers’ luggage, and 1 kg of mail registered for the UTA120 flight. The fuel on board was 2000 kg, the A/C TOW was 18730 kg, the A/C weight balance was 30.72% mean aerodynamic chord. The TOW and weight balance were inside the AFM (FCOM) limitations. According to an avionics technician's statements the crew arrived to the A/C around 00:30. By the external observation video camera records it can be seen that the PIC performed the preflight inspection very briefly. He lingered for a few minutes by the right engine then moved along the fuselage sides, then stopped by the left main gear, and finally went into the cockpit. The after-inspection FTLB entry made by the PIC was: "LC PERFORMED BY CDR", the PIC also put the time of inspection which was 00:40 and quantity of fuel 2000 kg. There were no remarks made against the A/C condition in the FTLB. By the records of the external observation video camera, it can be seen that at 01:13 the boarding had been completed and the entrance door was closed. So, the A/C had been remaining at the AD under the influence of precipitations in the form of rain and wet snow with ambient temperature around zero degrees Celsius and wind velocity more than 10 m/s for more than 7 hours. There was no de/anti-icing treatment performed for the A/C before the flight. At 01:20 the flight crew performed the engine start, and after that passed through the Before Taxi checklist. At 01:24:46 the flight crew obtained clearance for holding position. At 01:32:08 after clearance for lineup position the flight crew reported: “Lining up”. At 01:32:58 the A/C started taking off. The takeoff was performed with flaps extended at 15°. The A/C lift-off occurred at 01:33:28 with a speed of around ≈127 kt. At 01:33:56 at height 600 ft2 and speed of 135 kt the A/P was engaged. At 01:34:00 at height 640 ft and speed of 139 kt the flaps retraction was started. At 01:34:08 after the retraction had been completed, at 690 ft and at a speed of 150 kt uncommanded development of right bank started. At 01:34:10 the A/P was disengaged. The bank angle reached around 40° to the right within 3 s and after that was counteracted by ailerons and rudder deflection. Further, the A/C banked to the left, which the flight crew was not able to compensate with full deflection of ailerons to the right. The A/C collision into terrain occurred at 01:34:35 with a pitch down angle ≈11°, left bank angle ≈55° and vertical rate of descent over 20 m/s. The ASL elevation of the accident area is about ≈110 m. The accident resulted in the A/C full destruction and partial damage by the ground fire. From the 43 persons onboard 4 crew members and 29 passengers were killed. Others sustained serious injuries.

The aircraft was carrying 50 passengers and a crew of five from Juba to Wau. After landing, the left main gear collapsed. The aircraft skidded on the 2,175 metres long and unpaved runway, veered off and came to rest with its nose gear torn off. While all five crew members were injured, all 50 passengers escaped uninjured. The aircraft was damaged beyond repair. The airport reported that the first part of runway 09 was closed due to work in progress since three months. It appears from various sources that the airline reported there was no NOTAM indicating the work in progress to resurface the runway and tower did not advise about the work in progress, too. Due to the slope of the runway it was impossible to see the workers on the runway in time. After landing, the aircraft impacted obstacles and went out of control.

After the pilot finished the preflight inspection in the hangar, the maintenance technician pulled the airplane out of the hangar and connected the auxiliary power cart to the airplane. Shortly thereafter, the pilot boarded the airplane and proceeded with the normal checklist. The pilot signaled to the maintenance technician to disconnect the power cart. The maintenance technician subsequently signaled that the pilot was clear to start the engines. After departure, the pilot noted a problem with the landing gear, and, after establishing that the tow bar was, most likely, still attached to the nosewheel, he diverted to a nearby airport for a precautionary landing. During the landing, the nose landing gear collapsed and the primary structure in the nose of the airplane was substantially damaged.

A witness reported that the airplane veered left during the takeoff roll and headed toward a large ditch that surrounded the runway. It appeared that the pilot did not attempt to stop the airplane or abort the takeoff. The airplane continued toward the ditch, and, upon reaching the ditch's edge, the airplane rotated and reached an altitude of about 50 feet. The airplane's left wing collided with trees. The airplane rolled left and then right before stalling and crashing. The pilot stated that the airplane seemed to pull left on takeoff, possibly due to a right quartering tailwind, and that he did not realize where he was positioned on the runway. Examination of the airplane and engine did not reveal any preimpact anomalies that would have precluded normal operation.