Crash of a Boeing 737-476 in Bergamo

Date & Time: Aug 5, 2016 at 0407 LT
Type of aircraft:
Operator:
Registration:
HA-FAX
Flight Type:
Survivors:
Yes
Schedule:
Paris-Roissy-CDG - Bergamo
MSN:
24437/2162
YOM:
1991
Flight number:
QY7332
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9787
Captain / Total hours on type:
2254.00
Copilot / Total flying hours:
343
Copilot / Total hours on type:
86
Aircraft flight hours:
65332
Circumstances:
The aircraft departed Paris-Roissy-Charles de Gaulle Airport at 0254LT on a cargo flight (service QY7332) to Bergamo on behalf of DHL Airways. Upon arrival at Bergamo-Orio al Serio Airport, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong wind. The aircraft crossed the runway threshold at a speed of 156 knots and landed 18 seconds later, 2,000 metres pas the runway threshold. Unable to stop within the remaining distance (runway 28 is 2,807 metres long), the aircraft overran, went through the perimeter fence, lost its undercarriage and both engines and eventually stopped in a motorway, some 520 metres pas the runway end. Both crew members evacuated safely and the aircraft was destroyed.
Probable cause:
The causes of the accident are mainly due to the human factor. In particular, the accident was caused by the runway overrun during the landing phase, caused by a loss of situational awareness relating to the position of the aircraft with respect to the runway itself. This loss of situational awareness on the part of the crew caused a delay in contact with the runway, which occurred, at a still high speed, in a position too far to allow the aircraft to stop within the remaining distance.
Contributing to the dynamics of the event:
- The commander's prior decision not to carry out a go-around procedure (this decision is of crucial importance in the chain of events that characterized the accident),
- Inadequate maintenance of flight parameters in the final phase of landing,
- Failure of the crew to disconnect the autothrottle prior to landing,
- Poor lighting conditions with the presence of storm cells and heavy rain falls at the time of the event (environmental factor), which may have contributed to the loss of situation awareness,
- The attention paid by the crew during the final phase of the flight, where both pilots were intent to acquire external visual references and did not realize that the aircraft crossed over the runway at high speed for 18 seconds before touchdown,
- The lack of assertiveness of the first officer in questioning the commander's decisions.
Finally, it cannot be excluded that a condition of tiredness and fatigue may have contributed to the accident, even if not perceived by the crew, which may have influenced the cognitive processes, in particular those of the captain, interfering with his correct decision making process.
Final Report:

Crash of an Airbus A320-232 in the Mediterranean Sea: 66 killed

Date & Time: May 19, 2016 at 0229 LT
Type of aircraft:
Operator:
Registration:
SU-GCC
Flight Phase:
Survivors:
No
Schedule:
Paris – Cairo
MSN:
2088
YOM:
2003
Flight number:
MS804
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
56
Pax fatalities:
Other fatalities:
Total fatalities:
66
Captain / Total flying hours:
6275
Captain / Total hours on type:
2101.00
Copilot / Total flying hours:
2675
Aircraft flight hours:
48000
Circumstances:
The aircraft departed Paris-Roissy-Charles de Gaulle Airport at 2321LT on May 18 on an international schedule flight to Cairo. carrying 56 passengers and 10 crew members. The crew maintained radio contacts with the Greek ATC and was transferred to the Egyptian ATC but failed to respond. Two minutes after the airplane left the Greek Airspace, the aircraft descended from FL370 to FL220 in few seconds, apparently making a first turn to the left and then a 360 turn to the right before disappearing from the radar screen at 0229LT while at an altitude of 10'000 feet. It is believed that the aircraft crashed in the Mediterranean sea about 200 km north of Egyptian coast. The crew did not send any mayday message, thereby all assumptions remains open. It appears that some various debris such as luggage were found on May 20 about 290-300 km north of Alexandria. Two days after the accident, it is confirmed that ACARS messages reported smoke on board, apparently in the lavatory and also in a technical compartment located under the cockpit area. Above that, several technical issues were reported by the ACARS system. The CVR has been recovered on June 16, 2016, and the DFDR a day later. As both recorder systems are badly damaged, they will need to be repaired before analyzing any datas. On December 15, 2016, investigators reported that traces of explosives were found on several victims. Egyptian authorities determined that there had been a malicious act. The formal investigation per ICAO Annex 13 was stopped and further investigation fell within the sole jurisdiction of the judicial authorities. Contradicting the Egyptian finding, the French BEA considered that the most likely hypothesis was that a fire broke out in the cockpit while the aircraft was flying at its cruise altitude and that the fire spread rapidly resulting in the loss of control of the aircraft.

Crash of a Boeing 737-476SF in East Midlands

Date & Time: Apr 29, 2014 at 0228 LT
Type of aircraft:
Operator:
Registration:
EI-STD
Flight Type:
Survivors:
Yes
Schedule:
Paris-Roissy-Charles de Gaulle – East Midlands
MSN:
24433/1881
YOM:
1990
Flight number:
ABR1748
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4279
Captain / Total hours on type:
377.00
Copilot / Total flying hours:
3900
Circumstances:
The aircraft was scheduled to operate three commercial air transport (cargo) sectors: from Athens to Bergamo, then to Paris Charles de Gaulle, and finally East Midlands. The aircraft’s flap load relief system was inoperative, which meant that the maximum flap position to be used in flight was 30, rather than 40º. This defect had been deferred in the aircraft’s technical log and it had no effect on the landing of the aircraft. Otherwise, the aircraft was fully serviceable. The co-pilot completed the pre-flight external inspection of the aircraft in good light, and found nothing amiss. The departure from Athens was uneventful, but a combination of factors affecting Bergamo (including poor weather, absence of precision approach aids, and work in progress affecting the available landing distance) led the crew to decide to route directly to Paris, where a normal landing was carried out. The aircraft departed Paris for East Midlands at 0040 hrs, loaded with 10 tonnes of freight, 8 tonnes of fuel (the minimum required was 5.6 tonnes), and with the co-pilot as Pilot Flying. Once established in the cruise, the flight crew obtained the latest ATIS information from East Midlands, which stated that Runway 27 was in use, although there was a slight tailwind, and Low Visibility Procedures (LVPs) were in force. They planned to exchange control at about FL100 in the descent, for the commander to carry out a Category III autoland. However, as they neared their destination, the weather improved, LVPs were cancelled, and the flight crew re-briefed for an autopilot approach, followed by a manual landing, to be carried out by the co-pilot. The landing was to be with Flap 30, Autobrake 2, and idle reverse thrust. The final ATIS transmission which the flight crew noted before landing stated that the wind was 130/05 kt, visibility was 3,000 metres in mist, and the cloud was broken at 600 ft aal. The commander of EI-STD established radio contact with the tower controller, and the aircraft was cleared to land; the surface wind was transmitted as 090/05 kt. The touchdown was unremarkable, and the autobrake functioned normally, while the co-pilot applied idle reverse thrust on the engines. As the aircraft’s speed reduced through approximately 60 kt, the co-pilot handed control to the commander, who then made a brake pedal application to disengage the autobrake system. However, the system remained engaged, so he made a second, more positive, brake application. The aircraft “shuddered” and rolled slightly left-wing-low as the lower part of the left main landing gear detached. The commander used the steering tiller to try to keep the aircraft tracking straight along the runway centreline, but it came to a halt slightly off the centreline, resting on its right main landing gear, the remains of the left main landing gear leg, and the left engine lower cowl. The co-pilot saw some smoke drift past the aircraft as it came to a halt. The co-pilot made a transmission to the tower controller, reporting that the aircraft was in difficulties, after which the co-pilot of another aircraft (which was taxiing from its parking position along the parallel taxiway) made a transmission referring to smoke from the 737’s landing gear. The commander of EI-STD had reached the conclusion that one of the main landing gear legs had failed, but as a result of the other pilot’s transmission, he was also concerned that the aircraft might be on fire. The commander immediately moved both engine start levers to the cut-off positions, shutting down the engines. Three RFFS vehicles had by now arrived at the adjacent taxiway intersection, and their presence there prompted the commander to consider that the aircraft was not on fire (he believed that if it were, the vehicles would have adopted positions closer by and begun to apply fire-fighting media). The RFFS vehicles then moved closer to the aircraft and fire-fighters placed a ladder against door L1, which the co-pilot had opened. Having spoken to fire-fighters while standing in the entrance vestibule, the commander returned to the flight deck and switched off the battery. The flight crew were assisted from the aircraft and fire-fighters applied foam around the landing gear and engine to make the area safe. The commander had taken the Notoc2 with him from the aircraft, and informed fire-fighters of the dangerous goods on board the aircraft.
Probable cause:
The damage to the flap system, fuselage, and MLG equipment was attributable to the detachment of the left MLG axle, wheel and brake assembly. The damage to the MLG outer cylinder, engine and nacelle was as result of the aircraft settling and sliding along the runway. The left MLG axle assembly detached from the inner cylinder due to the momentary increase in bending load during the transition from auto to manual braking. The failure was as a result of stress corrosion cracking and fatigue weakening the high strength steel substrate at a point approximately 75 mm above the axle. It is likely that some degree of heat damage was sustained by the inner cylinder during the overhaul process, as indicated by the presence of chicken wire cracking within the chrome plating over the majority of its surface. However, this was not severe enough to have damaged the steel substrate and therefore may have been coincidental. Although the risk of heat damage occurring during complex landing gear plating and refinishing processes is well understood and therefore mitigated by the manufacturers and overhaul agencies, damage during the most recent refinishing process cannot be discounted. The origin of the failure was an area of intense, but very localized heating, which damaged the chrome protection and changed the metallurgy; ie the formation of martensite within the steel substrate. This resulted in a surface corrosion pit, which, along with the metallurgical change, led to stress corrosion cracking, fatigue propagation and the eventual failure of the inner cylinder under normal loading.
Final Report:

Crash of a Saab 2000 in Paris-Roissy-CDG

Date & Time: Jan 28, 2014 at 0731 LT
Type of aircraft:
Operator:
Registration:
HB-IZG
Survivors:
Yes
Schedule:
Leipzig – Paris
MSN:
010
YOM:
1994
Flight number:
DWT250
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6640
Captain / Total hours on type:
2260.00
Copilot / Total flying hours:
630
Copilot / Total hours on type:
80
Circumstances:
Following an uneventful flight from Leipzig, the crew started the descent to Paris-Roissy-CDG Airport runway 27R. At an altitude of 400 feet on approach, the automatic pilot system was deactivated. At an altitude of 200 feet, the decision height, the crew decided to continue the approach as the runway was in sight and the aircraft was stable. During the last segment, at a height of 50 feet, power levers were reduced to flight idle and the aircraft went into a nose up attitude (maximum value of 11°). Both main gears touched down at a speed of 120 knots but the aircraft bounced twice and went into a pitch down attitude, causing the nose gear to land first during the third touchdown. On impact, the nose gear collapsed and the aircraft slid for dozen yards before coming to rest. All 19 occupants were evacuated safely and the aircraft was later considered as damaged beyond repair.
Probable cause:
During the flare the captain detected that the landing would be hard and in an emergency action, he quickly pulled the nose up without announcing his intention to the first officer who was the pilot flying. This lack of coordination within the flight crew caused a double controls and successive and opposite actions on the flight controls during the bouncing management.
Final Report:

Mishap of a Fokker F27 Friendship 500F in Paris-Roissy-CDG

Date & Time: Oct 25, 2013 at 0125 LT
Type of aircraft:
Operator:
Registration:
I-MLVT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Dole
MSN:
10373
YOM:
1968
Flight number:
MNL5921
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a night mail flight from Paris-Roissy-CDG Airport to Dole-Jura (Tavaux) Airport on behalf of Europe Airpost. Shortly after takeoff, while climbing to an altitude of 1,000 feet, the left propeller detached and impacted the left part of the fuselage, causing a large hole. The crew declared an emergency and was cleared for an immediate return. The aircraft landed safely less than 10 minutes later and was parked on the apron. Both pilots were uninjured and the aircraft was damaged beyond repair. The propeller was found in an open field in Mesnil-Amelot, near the airport. Nobody on ground was injured.
Probable cause:
The n°2 propeller blade root on the left engine failed due to fatigue, resulting in separation from the propeller hub and then interaction with the n°1 blade and its disconnection from the propeller hub. The imbalance created by the loss of these two blades led to the front part of the engine being torn off. The cause of the fatigue cracking could not be determined with certainty. The following may have contributed to the fatigue fracture of the propeller blade root:
- Insufficient preloading of the propeller, increasing the stress exerted on it. The lack of maintenance documentation made it impossible to determine the preload values of the bearings during the last general overhaul;
- The presence of manganese sulphide in a heavily charged area of the propeller. The presence of this sulphide may have generated a significant stress concentration factor, raising the local stress level.
The tests and research carried out as part of this investigation show that the propeller blade root is made of a steel whose microstructure and composition are not optimal for fatigue resistance. However, the uniqueness of the rupture more than 50 years after commissioning makes it unlikely that the rate of inclusions, their distribution, size, or sulphur content of the propeller is a contributing factor in the accident.
Final Report: