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Crash of a Boeing 747-412F in Bishkek: 39 killed

Date & Time: Jan 16, 2017 at 0719 LT
Type of aircraft:
Operator:
Registration:
TC-MCL
Flight Type:
Survivors:
No
Site:
Schedule:
Hong Kong - Bishkek - Istanbul
MSN:
32897/1322
YOM:
2003
Flight number:
TK6491
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
39
Captain / Total flying hours:
10808
Captain / Total hours on type:
820.00
Copilot / Total flying hours:
5894
Copilot / Total hours on type:
1758
Aircraft flight hours:
46820
Aircraft flight cycles:
8308
Circumstances:
On 16.01.2017, the crew of the Boeing 747-412F TC-MCL aircraft was performing a THY6491 flight from Hong Kong via Bishkek (Manas Airport) to Istanbul (Ataturk Airport) in order to transport the commercial cargo (public consumer goods) of 85 618 kg. The cargo was planned to be offloaded in Istanbul (Ataturk Airport). Manas Airport was planned as a transit airport for crew change and refueling. From 12.01.2017 to 15.01.2017, the crew had a rest period of 69 h in a hotel in Hong Kong. The aircraft takeoff from the Hong Kong Airport was performed at 19:12 on 5.01.2017, with the delay of 2 h 02 min in respect to the planned takeoff time. During the takeoff, the climb and the on-route cruise flight, the aircraft systems operated normally. At 00:41, on 16.01.2017, the aircraft entered the Bishkek ATC Area Control Center over the reference point of KAMUD at flight level of 10 400 m (according to the separation system, established in the People's Republic of China). At 00:51, the crew requested a descent and reached the FL 220 (according to the separation system, established in the Kyrgyz Republic). At 00:59, the crew received the weather information for Manas Airport: "the RVR at the RWY threshold 400 m, the RWY midpoint and RWY end 300 m, the vertical visibility 130 ft". At 01:01, the crew received the specified data: " in the center of the runway RVR three zero zero meters, vertical visibility one five zero feet." At 01:03, the crew requested a descent, the controller cleared for the descent not below FL 180. At 01:05, the crew was handed over to the Approach Control. At 01:06, the crew was cleared for the descent to FL 60, TOKPA 1 ILS approach chart, RWY 26. At 01:10, the controller reported the weather: wind calm, visibility 50 m, RVR 300 m, freezing fog, vertical visibility 160 ft, and requested the crew if they would continue the approach. The crew reported that they would continue the approach. The crew conducted the approach to RWY 26 in accordance with the standard approach chart. At 01:11, the controller informed the crew: "… transition level six zero" and cleared them for the ILS approach to RWY 26. At 01:15, the crew contacted the Tower controller. The Tower controller cleared them for landing on RWY 26 and reported the weather: "…wind calm… RVR in the beginning of the runway four hundred meters, in the middle point three hundred two five meters and at the end of the runway four hundred meters and vertical visibility one six zero... feet". The aircraft approached the RWY 26 threshold at the height significantly higher than the planned height. Continuing to descend, the aircraft flew over the entire length of the RWY and touched the ground at the distance of 900 m away from the farthest end of the runway (in relation to the direction of the approach) (the RWY 08 threshold). After the touchdown and landing roll, the aircraft impacted the concrete aerodrome barrier and the buildings of the suburban settlement and started to disintegrate, the fuel spillage occurred. As a result of the impact with the ground surface and the obstacles, the aircraft was completely disintegrated, a significant part of the aircraft structure was destroyed by the post-crash ground fire. At 01.17 UTC, the Tower controller requested the aircraft position, but the crew did not respond.
Probable cause:
The cause of the Boeing 747-412F TC-MCL aircraft accident was the missing control of the crew over the aircraft position in relation to the glideslope during the automatic approach, conducted at night in the weather conditions, suitable for ICAO CAT II landing, and as a result, the measures to perform a go-around, not taken in due time with the aircraft, having a significant deviation from the established approach chart, which led to the controlled flight impact with terrain (CFIT) at the distance of ≈930 m beyond the end of the active RWY.
The contributing factors were, most probably, the following:
- the insufficient pre-flight briefing of the flight crew members for the flight to Manas aerodrome (Bishkek), regarding the approach charts, as well as the non-optimal decisions taken by the crew when choosing the aircraft descent parameters, which led to the arrival at the established approach chart reference point at a considerably higher flight altitude;
- the lack of the crew's effective measures to decrease the aircraft vertical position and its arrival at the established approach chart reference point while the crew members were aware of the actual aircraft position being higher than required by the established chart;
- the lack of the requirements in the Tower controllers' job instructions to monitor for considerable aircraft position deviations from the established charts while the pertinent technical equipment for such monitoring was available;
- the excessive psycho-emotional stress of the crew members caused by the complicated approach conditions (night time, CAT II landing, long-lasting working hours) and their failure to eliminate the flight altitude deviations during a long time period. Additionally, the stress level could have been increased due to the crew's (especially the PIC's) highly emotional discussion of the ATC controllers' instructions and actions. Moreover, the ATC controllers' instructions and actions were in compliance with the established operational procedures and charts;
- the lack of the crew members' monitoring for crossing the established navigational reference points (the glideslope capture point, the LOM and LIM reporting points);
- the crew's failure to conduct the standard operational procedure which calls for altitude verification at the FAF/FAP, which is stated in the FCOM and the airline's OM. On the other hand, the Jeppesen Route Manual, used by the crew, contains no FAF/FAP in the RWY 26 approach chart;
- the onboard systems' "capture" of the false glideslope beam with the angle of ≈9°;
- the design features of the Boeing 747-400 aircraft type regarding the continuation of the aircraft approach descent in the automatic mode with the constant descent angle of 3° (the inertial path) with the maintained green indication of the armed automatic landing mode (regardless of the actual aircraft position in relation to the RWY) while the aircraft systems detected that the glideslope signal was missing (after the glideslope signal "capture"). With that, the crew received the designed annunciation, including the aural and visual caution alerts;
- the absence of the red warning alert for the flight crew in case of a "false" glideslope capture and the transition to the inertial mode trajectory, which would require immediate control actions from the part of the crew;
- the lack of monitoring from the part of the crew over the aircraft position in regard to the approach chart, including the monitoring by means of the Navigation Display (ND), engaged in the MAP mode;
- the crew's failure to conduct the Airline's Standard Operational Procedures (SOPs), regarding the performance of the go-around procedure in case the "AUTOPILOT" (the AP switching to the inertial mode) and "GLIDESLOPE" (the EGPWS annunciation of the significant glideslope deviation) alerts during the automatic CAT II landing at true heights below 1000 ft (with no visual reference established with either the runway environment or with the lighting system);
- the delayed actions for initiating the go-around procedure with no visual reference established with the runway environment at the decision height (DH). In fact, the actions were initiated at the true height of 58 ft with the established minimum of 99 ft.
Final Report:

Crash of a Boeing 747-209B off Magong: 225 killed

Date & Time: May 25, 2002 at 1529 LT
Type of aircraft:
Operator:
Registration:
B-18255
Flight Phase:
Survivors:
No
Schedule:
Taipei - Hong Kong
MSN:
21843
YOM:
1979
Flight number:
CI1611
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
206
Pax fatalities:
Other fatalities:
Total fatalities:
225
Captain / Total flying hours:
10148
Captain / Total hours on type:
4732.00
Copilot / Total flying hours:
10173
Copilot / Total hours on type:
5831
Aircraft flight hours:
64810
Aircraft flight cycles:
21398
Circumstances:
On May 25, 2002, China Airlines (CAL) CI611, a Boeing 747-200, Republic of China (ROC) registration B-18255, was a regularly scheduled flight from Chiang Kai Shek International Airport (CKS), Taoyuan, Taiwan, ROC to Chek Lap Kok International Airport, Hong Kong. Flight CI611 was operating in accordance with ROC Civil Aviation Administration (CAA) regulations. The captain (Crew Member-1, CM-1) reported for duty at 1305 , at the CAL CKS Airport Dispatch Office and was briefed by the duty dispatcher for about 20 minutes, including Notices to Airmen (NOTAM) regarding the TPE Flight Information Region (FIR). The first officer (Crew Member-2, CM-2) and flight engineer (Crew Member-3, CM-3) reported for duty at CAL Reporting Center, Taipei, and arrived at CKS Airport about 1330. The aircraft was prepared for departure with two pilots, one flight engineer, 16 cabin crew members, and 206 passengers aboard. The crew of CI611 requested taxi clearance at 1457:06. At 1507:10, the flight was cleared for takeoff on Runway 06 at CKS. The takeoff and initial climb were normal. The flight contacted Taipei Approach at 1508:53, and at 1510:34, Taipei Approach instructed CI611 to fly direct to CHALI. At 1512:12, CM-3 contacted China Airlines Operations with the time off-blocks, time airborne, and estimated time of arrival at Chek Lap Kok airport. At 1516:24, the Taipei Area Control Center controller instructed CI611 to continue its climb to flight level 350, and to maintain that altitude while flying from CHALI direct to KADLO4. The acknowledgment of this transmission, at 1516:31, was the last radio transmission received from the aircraft. Radar contact with CI611 was lost by Taipei Area Control at 1528:03. An immediate search and rescue operation was initiated. At 1800, floating wreckage was sighted on the sea in the area 23 nautical miles northeast of Makung, Penghu Islands. The aircraft was totally destroyed and all 225 occupants were killed.
Probable cause:
Findings related to probable causes:
1. Based on the recordings of CVR and FDR, radar data, the dado panel open-close positions, the wreckage distribution, and the wreckage examinations, the in-flight breakup of CI611, as it approached its cruising altitude, was highly likely due to the structural failure in the aft lower lobe section of the fuselage.
2. In February 7 1980, the accident aircraft suffered a tail strike occurrence in Hong Kong. The aircraft was ferried back to Taiwan on the same day un-pressurized and a temporary repair was conducted the day after. A permanent repair was conducted on May 23 through 26, 1980.
3. The permanent repair of the tail strike was not accomplished in accordance with the Boeing SRM, in that the area of damaged skin in Section 46 was not removed (trimmed) and the repair doubler did not extend sufficiently beyond the entire damaged area to restore the structural strength.
4. Evidence of fatigue damage was found in the lower aft fuselage centered about STA 2100, between stringers S-48L and S-49L, under the repair doubler near its edge and outside the outer row of securing rivets. Multiple Site Damage (MSD), including a 15.1-inch through thickness main fatigue crack and some small fatigue cracks were confirmed. The 15.1-inch crack and most of the MSD cracks initiated from the scratching damage associated with the 1980 tail strike incident.
5. Residual strength analysis indicated that the main fatigue crack in combination with the Multiple Site Damage (MSD) were of sufficient magnitude and distribution to facilitate the local linking of the fatigue cracks so as to produce a continuous crack within a two-bay region (40 inches). Analysis further indicated that during the application of normal operational loads the residual strength of the fuselage would be compromised with a continuous crack of 58 inches or longer length. Although the ASC could not determine the length of cracking prior to the accident flight, the ASC believes that the extent of hoop-wise fretting marks found on the doubler, and the regularly spaced marks and deformed cladding found on the fracture surface suggest that a continuous crack of at least 71 inches in length, a crack length considered long enough to cause structural separation of the fuselage, was present before the in-flight breakup of the aircraft.
6. Maintenance inspection of B-18255 did not detect the ineffective 1980 structural repair and the fatigue cracks that were developing under the repair doubler. However, the time that the fatigue cracks propagated through the skin thickness could not be determined.
Final Report:

Crash of a McDonnell Douglas MD-11 in Hong Kong: 3 killed

Date & Time: Aug 22, 1999 at 1843 LT
Type of aircraft:
Operator:
Registration:
B-150
Survivors:
Yes
Schedule:
Bangkok - Hong Kong - Taipei
MSN:
48468
YOM:
1992
Flight number:
CI642
Country:
Region:
Crew on board:
15
Crew fatalities:
Pax on board:
300
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17900
Captain / Total hours on type:
3260.00
Copilot / Total flying hours:
4630
Copilot / Total hours on type:
2780
Aircraft flight hours:
30700
Aircraft flight cycles:
5800
Circumstances:
China Airline’s flight CI642 was scheduled to operate from Bangkok to Taipei with an intermediate stop in Hong Kong. The crew had carried out the sector from Taipei to Bangkok, passing through Hong Kong on the previous day. On that flight, the crew were aware of the Severe Tropical Storm (STS) ‘Sam’ approaching Hong Kong and the possibility that it would be in the vicinity of Hong Kong at about the scheduled time of arrival on the following evening. Weather information provided at the preflight briefing for the return flight indicated the continuing presence of STS ‘Sam’ with its associated strong winds and heavy precipitation. The flight departed from Bangkok on schedule with 300 passengers and 15 crew on board, with an estimated time of arrival (ETA) of 1038 hour (hr) in Hong Kong. The commander had elected to carry sufficient fuel to permit a variety of options on arrival – to hold, to make an approach, or to divert. If an immediate approach was attempted, the aircraft would be close to its Maximum Landing Weight (MLW) involving, in consequence, a relatively high speed for the approach and landing. Throughout the initial stages of the flight and during the cruise, the commander was aware of the crosswind component to be expected in Hong Kong and reviewed the values of wind direction and speed which would bring it within the company’s crosswind limit as applicable to wet runways of 24 kt. In the latter stage of the cruise, the crew obtained information ‘Whisky’ from the Automatic Terminal Information Service (ATIS) timed at 0940 hr, which gave a mean surface wind of 320 degrees (º) / 30 knots (kt) maximum 45 kt in heavy rain, and a warning to expect significant windshear and severe turbulence on the approach. Although this gave a crosswind component of 26 kt which was in excess of the company’s wet runway limit of 24 kt, the commander was monitoring the gradual change in wind direction as the storm progressed, which indicated that the wind direction would possibly shift sufficiently to reduce the component and thus permit a landing. Hong Kong Area Radar Control issued a descent clearance to the aircraft at 1014 hr and, following receipt of ATIS information ‘X-ray’ one minute later, which included a mean surface wind of 300º at 35 kt, descent was commenced at 1017 hr. Copies of the information sheets used by Air Traffic Control (ATC) as the basis for ATIS broadcasts ‘Whisky’ and ‘X-ray’ are at Appendix 1. The approach briefing was initiated by the commander just after commencing descent. The briefing was given for an Instrument Landing System (ILS) approach to Runway 25 Right (RW 25R) at HKIA. However, the active runway, as confirmed by the ATIS was RW 25L. Despite the inclusion in the ATIS broadcasts of severe turbulence and possible windshear warnings, no mention was made in the briefing of the commander’s intentions relating to these weather phenomena nor for any course of action in the event that a landing could not be made, other than a cursory reference to the published missed approach procedure. The descent otherwise continued uneventfully and a routine handover was made at 1025 hr to Hong Kong Approach Control which instituted radar vectoring for an ILS approach to what the crew still believed was RW 25R. At 1036 hr, after having been vectored through the RW 25L localizer for spacing, CI642 was given a heading of 230º to intercept the localizer from the right and cleared for ILS to RW 25L. The co-pilot acknowledged the clearance for ILS 25L but queried the RVR (runway visual ranges); these were passed by the controller, the lowest being 1300 m at the touchdown point. The commander then quickly re-briefed the minimums and go-around procedure for RW 25L. At 1038 hr, about 14 nautical miles (nm) to touchdown, the aircraft was transferred to Hong Kong Tower and told to continue the approach. At 1041 hr, the crew were given a visibility at touchdown of 1600 metres (m) and touchdown wind of 320º at 25 kt gusting 33 kt, and cleared to land. The crew of flight CI642 followed China Airline’s standard procedures during the approach. Using the autoflight modes of the aircraft, involving full use of autopilot and autothrottle systems, the flight progressed along the ILS approach until 700 ft where the crew became visual with the runway and approach lights of RW 25L. Shortly after this point the commander disconnected the autopilot and flew the aircraft manually, leaving the autothrottle system engaged to control the aircraft’s speed. After autopilot disconnect, the aircraft continued to track the runway centreline but descended and stabilized slightly low (one dot) on the glideslope. Despite the gustiness of the wind, the flight continued relatively normally for the conditions until approximately 250 ft above the ground at which point the co-pilot noticed a significant decrease in indicated airspeed. Thrust was applied as the co-pilot called ‘Speed’ and, as a consequence, the indicated airspeed rose to a peak of 175 kt. In response to this speed in excess of the target approach speed, thrust was reduced and, in the process of accomplishing this, the aircraft passed the point (50 ft RA) at which the autothrottle system commands the thrust to idle for landing. Coincidentally with this, the speed decreased from 175 kt and the rate of descent began to increase in excess of the previous 750-800 feet per minute (fpm). Although an attempt was made to flare the aircraft, the high rate of descent was not arrested, resulting in an extremely hard impact with the runway in a slightly right wing down attitude (less than 4º), prior to the normal touchdown zone. The right mainwheels contacted the runway first, followed by the underside of the right engine cowling. The right main landing gear collapsed outward, causing damage to the right wing assembly, resulting in its failure. As the right wing separated, spilled fuel was ignited and the aircraft rolled inverted and came to rest upside-down alongside the runway facing in the direction of the approach. The cockpit crew were disorientated by the inverted position of the aircraft and found difficulty in locating the engine controls to carry out engine shut down drills. After extricating themselves, they went through the cockpit door into the cabin and exited the aircraft through L1 door and began helping passengers from the aircraft through a hole in the fuselage. Airport fire and rescue services were quickly on the scene, extinguishing the fuel fire and evacuating the passengers through the available aircraft exits and ruptures in the fuselage. As a result of the accident, two passengers were found dead on arrival at hospital, and six crew members and 45 passengers were seriously injured. One of the seriously injured passengers died five days later in hospital.
Probable cause:
The cause of the accident was the commander’s inability to arrest the high rate of descent existing at 50 feet RA. Probable contributory causes to the high rate of descent were:
- The commander’s failure to appreciate the combination of a reducing airspeed, increasing rate of descent, and with the thrust decreasing to flight idle.
- The commander’s failure to apply power to counteract the high rate of descent prior to touchdown.
- Probable variations in wind direction and speed below 50 feet RA may have resulted in a momentary loss of headwind component and, in combination with the early retardation of the thrust levers, and at a weight only just below the maximum landing weight, led to a 20 kt loss in indicated airspeed just prior to touchdown. A possible contributory cause may have been a reduction in peripheral vision as the aircraft entered the area of the landing flare, resulting in the commander not appreciating the high rate of descent prior to touchdown.
Final Report: