Crash of a Raytheon 390 Premier IA in Samedan: 2 killed

Date & Time: Dec 19, 2010 at 1502 LT
Type of aircraft:
Operator:
Registration:
D-IAYL
Flight Type:
Survivors:
No
Schedule:
Zagreb - Samedan
MSN:
RB-249
YOM:
2008
Flight number:
GQA631V
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4306
Captain / Total hours on type:
244.00
Copilot / Total flying hours:
1071
Copilot / Total hours on type:
567
Aircraft flight hours:
1047
Aircraft flight cycles:
820
Circumstances:
After an uneventful flight, the IFR flight plan was cancelled at 13:53:09 UTC and the flight continued under visual flight rules. When the crew were requested at 13:54:01 UTC by the Zurich sector south air traffic controller (ATCO) to switch to the Samedan Information frequency, they wanted to remain on the frequency for a further two minutes. The aircraft was on a south-westerly heading, approx. 5 km south of Zernez, when the crew informed the ATCO at 13:57:12 UTC that they would now change frequency. After first contact with Samedan Information, when the crew reported that they were ten miles before the threshold of runway 21, the aircraft was in fact approximately eight miles north-east of the threshold of runway 21. When at 13:58:40 UTC the crew of a Piaggio 180 asked the flight information service officer (FISO) of Samedan Information about the weather as follows: "(…) and the condition for inbound still ok?", the crew of D-IAYL responded at 13:58:46 UTC, before the FISO was able to answer: "Yes, for the moment good condition (…)". D-IAYL was slightly north-east of Zuoz when the crew asked the FISO about the weather over the aerodrome. D-IAYL was over Madulein when at 13:59:46 UTC the FISO informed the crew that they could land at their own discretion. Immediately afterwards, the crew increased their rate of descent to over 2200 ft/min and maintained this until a final recorded radio altitude (RA) of just under 250 ft, which they reached over the threshold of runway 21. The crew then initiated a climb to an RA of approximately 600 ft, turned a little to the left and then flew parallel to the runway centre line. The landing gear was extended and the flaps were set to 20 degrees with a high probability. At the end of runway 21 the crew initiated a right turn onto the downwind leg, during which they reached a bank angle of 55 degrees; in the process their speed increased from 110 to 130 knots. Abeam the threshold of runway 21, the crew turned onto the final approach on runway 21. The bank angle in this turn reached up to 62 degrees, without the speed being noticeably increased. The aircraft then turned upside down and crashed almost vertically. Both pilots suffered fatal injuries on impact. A power line was severed, causing a power failure in the Upper Engadine valley. An explosion-type fire broke out. The aircraft was destroyed.
Probable cause:
The accident is attributable to the fact that the aircraft collided with the ground, because control of the aircraft was lost due to a stall.
- The following causal factors have been identified for the accident:
- The crew continued the approach under weather conditions that no longer permitted safe control of the aircraft
- The crew performed a risky manoeuvre close to ground instead of a consistent missed approach procedure
- The fact that the flight information service did not consistently communicate to the crew relevant weather information from another aircraft was a contributing factor to the genesis of the accident
As a systemic factor that contributed to the genesis of the accident, the following point was identified:
- The visibility and cloud bases determined on Samedan airport were not representative for an approach from Zernez, because they did not correspond to the actual conditions in the approach sector.
Final Report:

Crash of a Cessna T303 Crusader near Zadar: 4 killed

Date & Time: Feb 5, 2009 at 1454 LT
Type of aircraft:
Operator:
Registration:
9A-DLN
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Zagreb – Zadar
MSN:
303-00089
YOM:
1981
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
20000
Copilot / Total flying hours:
3000
Circumstances:
The crew departed Zagreb Airport on a training flight to Zadar. While descending to Zadar Airport, he encountered marginal weather with icing conditions. At an altitude of 6,500 feet in clouds, the aircraft lost height and crashed in the Velebit Mountain Range. The aircraft was destroyed by impact forces and all four occupants were killed.
Probable cause:
The most probable cause of the accident is the entry with an uncertified aircraft into icing conditions and in mountain waves. The plane most likely froze on its tail first. After the plane most likely froze completely, it became too heavy, entered mountain waves, became completely uncontrollable, after which it crashed at a sharp angle from a height of about 6,500 feet and hit a hill at the foot of Vaganski Vrh. Due to the force of the impact, the plane completely disintegrated.
Final Report:

Crash of a Cessna T303 Crusader in Bratislava: 3 killed

Date & Time: Dec 10, 2007
Type of aircraft:
Operator:
Registration:
9A-DGV
Survivors:
No
Schedule:
Zagreb – Bratislava
MSN:
303-00186
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On approach to Bratislava-Ivanka-Milan Ratislav Štefánik Airport, the twin engine aircraft crashed in an open field located few kilometres from the airport, bursting into flames. All three occupants were killed. Weather conditions were marginal at the time of the accident.

Crash of a Let L-410UVP-E19A in Bergamo: 3 killed

Date & Time: Oct 30, 2005 at 2204 LT
Type of aircraft:
Operator:
Registration:
9A-BTA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Bergamo - Zagreb
MSN:
91 25 38
YOM:
1991
Flight number:
TDR729
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7780
Captain / Total hours on type:
760.00
Copilot / Total flying hours:
1272
Copilot / Total hours on type:
200
Aircraft flight hours:
7185
Circumstances:
The twin engine aircraft departed Bergamo-Orio al Serio Airport on a night cargo service to Zagreb, carrying one passenger (the captain's wife), two pilots and a load of 1,600 kilos of small packages. After takeoff from runway 28, while climbing in foggy conditions, the aircraft entered a left turn then descended, collided with a powerline and crashed in an open field located one km north of the airfield. The aircraft disintegrated on impact and all three occupants were killed.
Probable cause:
As far as is established, documented and substantiated, the cause of the accident is due to a loss of control in flight of the aircraft. Although the cause of this loss of control could not be established with incontrovertible certainty, it can reasonably be assumed that it was caused by a deterioration in the situation awareness of the crew during the initial climb immediately after take-off. The loss of such situation awareness may have been contributed jointly or severally:
- The displacement or incorrect positioning of the load, which would have induced a moment of rotation on the longitudinal axis of the aircraft (roll) not immediately perceived and counteracted by the crew;
- Spatial disorientation, as a result of the possible optical illusion produced by the high speed "E" TWY lights, which, crossing the thick fog, could have induced the pilot to veer, thus causing the final loss of control of the aircraft. In addition, the limited flight experience of the co-pilot and the inadequate application of CRM techniques by the crew did not allow for a timely identification of the hazardous situation and the necessary actions to recover the aircraft.
Final Report:

Crash of a PZL-Mielec AN-2R in Zagreb

Date & Time: Dec 6, 2001 at 1820 LT
Type of aircraft:
Operator:
Registration:
9A-BKA
Flight Type:
Survivors:
Yes
Schedule:
Slavonski Brod – Zagreb
MSN:
1G167-05
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a training flight from Zagreb to Slavonski Brod and back. After touchdown at Zagreb-Pleso Airport, the single engine airplane went out of control, nosed down and came to rest. All three occupants were rescued, among them one was slightly injured. The aircraft was damaged beyond repair.
Probable cause:
It was reported that the loss of control after landing was the consequence of the brakes lock.

Ground accident of a Fairchild-Hiller FH-227B in Zagreb

Date & Time: Jun 19, 1977
Type of aircraft:
Operator:
Registration:
YU-ALA
Flight Phase:
Survivors:
Yes
MSN:
525
YOM:
1966
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
43
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Suffered a ground accident while taxiing at Zagreb-Pleso Airport. All 47 occupants were evacuated safely while the aircraft was damaged beyond repair.

Crash of a Douglas DC-9-32 in Česká Kamenice: 27 killed

Date & Time: Jan 26, 1972 at 1701 LT
Type of aircraft:
Operator:
Registration:
YU-AHT
Flight Phase:
Survivors:
Yes
Schedule:
Stockholm – Copenhagen – Zagreb – Belgrade
MSN:
47482
YOM:
1970
Flight number:
JU367
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
27
Captain / Total flying hours:
8587
Captain / Total hours on type:
1306.00
Copilot / Total flying hours:
2369
Copilot / Total hours on type:
420
Aircraft flight hours:
2091
Aircraft flight cycles:
2564
Circumstances:
The airplane was completing a scheduled flight from Stockholm to Belgrade with intermediate stops in Copenhagen and Zagreb. After it passed the Czech border, while cruising at an altitude of 33,000 feet, the airplane disappeared from radar screens without the pilots having been able to transmit all or part of an emergency message. Debris were found near the city of Česká Kamenice, in the north of Czechoslovakia, near the East German border. 27 occupants were killed and a flight attendant, Mrs. Vesna Vujovic, was found alive on her seat located by the tail. Seriously wounded, she passed 18 months in a hospital.
Probable cause:
It was confirmed that the accident was the consequence of a terrorist act. Members of the Croatian Group called 'Ustasji' was able to place a homemade bomb in the forward cargo hold.
Final Report:

Crash of a Convair CV-440-11 Metropolitan in Trieste

Date & Time: Dec 16, 1971
Operator:
Registration:
YU-ADV
Survivors:
Yes
Schedule:
Zagreb - Trieste
MSN:
429
YOM:
1957
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing, the airplane went out of control, veered off runway and came to rest. All 22 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Ilyushin II-14M in Estenc: 7 killed

Date & Time: Nov 5, 1966 at 2002 LT
Type of aircraft:
Operator:
Registration:
TZ-ABH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Minsk – Zagreb – Marseille – Oran – Tamanrasset – Bamako
MSN:
7 34 25 01
YOM:
1957
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
15500
Copilot / Total flying hours:
1501
Aircraft flight hours:
3920
Circumstances:
The aircraft was on a ferry flight from Minsk, Belarus, to Bamako, Mali, with intermediate stops in Zagreb, Marseille, Oran and Tamanrasset. It was returning to its country following maintenance in Minsk factory. While cruising by night in poor weather conditions, the crew failed to realize that the airplane deviated from the prescribed flight path. Due to opposite traffic, the crew was instructed to make a 360° right turn but apparently did not understand this message. At an altitude of 10,000 feet, the airplane struck the slope of Mt L'Avalanche located about 1,500 meters west of Estenc, Alpes-Maritimes. The wreckage was found few hours later. The airplane was totally destroyed upon impact and all seven occupants, five crew members and two passengers (two mechanics) were killed. At the time of the accident, the airplane equipment was compliant but due to stormy weather and strong winds, a precise navigation was impossible due to the lack of a VOR receptor. On the route Genoa - Albenga - Nice, the airplane failed to follow the G7 Airway due to stormy weather and in accordance with ATC. The Russian pilot-in-command, speaking neither English nor French, could not converse directly with ground control. The co-pilot, speaking French but not Russian, could not converse directly with the captain or translate his orders from the ground. The navigator, in charge of the route in particular difficult conditions, could not correspond more with the pilot, if not by means of the radio. Only the radio could translate into Russian to the captain the indications provided in French by the ground control, which could ipso facto introduce a source of error of interpretation, and required a certain time of translation. The ICAO recommendation suggesting to the pilot-in-command the use of English or the language used by the ground station was not applied. The investigation established that the crew was unaware of wind and drift. Under the influence of a wind blowing from sector 210 to 100 km/h, the aircraft suffered a drift of about 20° towards the north, thus towards the mountain. Vertical to Nice, the airplane was already 25 kilometers north of the station and north of the G7 Airway. The diversion order did not have to be understood the first time since the crew requested repetition. The superposition of the orders of two simultaneous maneuvers, turn and descent, probably made the interpretation tricky and ambiguous. The order to make a 360° right turn, which means a circular turn, was erroneously understood as the order to take heading 360. Indeed, at least five kilometers prior to impact, the aircraft was following a straight path, in this case a heading oriented almost to magnetic north. Under the influence of one or more stormy areas northwest of Nice, the unstable indications of the radiocompas did not allow position's control and turbulences could create an additional difficulty. The aircraft approached the terrain as fast as it did to the north and the speed of the aircraft at that heading increased by about 100 km/h, representing the wind speed south-southeast. The point of impact was 2,440 meters, the level 80 towards which the aircraft was normally descending corresponding to an altitude of 2'380 meters.
Probable cause:
The commission of inquiry considers that the accident of the TZ-ABH is due to the accumulation of two main errors acting in the same direction. A navigational error due to the violence of an unknown or underestimated southern sector wind that caused a large uncorrected drift and caused the aircraft to crash. An error in the interpretation of a control order, due to a complexity of conversation exchanges. This error determined the pilot to take, from a position well north of the Airway, the 360​​° heading, which caused the aircraft to move further towards the terrain. This misinterpretation can itself be attributed to the fact that there is no international phraseology for the orders given by the control to the airplanes. These errors were aggravated by very bad weather conditions. These meteorological conditions: storms and very strong turbulences, could constitute aggravating causes by making difficult the work of the crew and in particular the navigation using the radiocompas medium frequency, the only radionavigation instruments the aircraft was equipped with. The fact that the aircraft was following an east-west route contrary to the flight plan forecast and that its altitude was too low given the route followed are still contributing factors.
Final Report: