Crash of an Antonov AN-24RV at Rogachevo AFB

Date & Time: Dec 14, 2010
Type of aircraft:
Operator:
Registration:
RA-47305
Survivors:
Yes
Schedule:
Arkhangelsk - Rogachevo
MSN:
5 73 103 05
YOM:
1975
Flight number:
AUL137
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
32
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 16 at Rogachevo AFB (Anderma-2), the aircraft encountered difficulties to stop within the remaining distance. It overran, lost its left main gear and came to rest 8 metres further. All 39 occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Beechcraft King Air 90 in Londrina

Date & Time: Dec 12, 2010 at 2140 LT
Type of aircraft:
Registration:
PT-WUG
Flight Type:
Survivors:
Yes
MSN:
LJ-1511
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Londrina-Governador José Richa airport in poor weather conditions, aircraft encountered windshear. It hit a small hill and eventually crashed in a field short of runway. All seven occupants injured and aircraft destroyed by fire.

Crash of a Tupolev TU-154M in Moscow: 2 killed

Date & Time: Dec 4, 2010 at 1436 LT
Type of aircraft:
Operator:
Registration:
RA-85744
Survivors:
Yes
Schedule:
Moscow - Makhatchkala
MSN:
92A-927
YOM:
1992
Flight number:
DAG372
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
160
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
17384
Captain / Total hours on type:
10000.00
Copilot / Total flying hours:
3111
Copilot / Total hours on type:
1150
Aircraft flight hours:
9285
Aircraft flight cycles:
2983
Circumstances:
Daghestan Airlines (Avialinii Dagestana) flight DAG372 departed Moscow-Vnukovo Airport at 1408LT bound for Makhatchkala, Daghestan. Fourteen minutes after takeoff, while cruising at an altitude of 9,000 metres some 80 kilometers south of Moscow, the crew informed ATC about the failure of the engines n°1 and 3 and was cleared to return to Moscow-Domodedovo Airport. On final, the aircraft descended below the clouds at a height of 500 feet but was not properly aligned with the runway centerline. It landed hard to the right of runway 32R, went out of control, impacted an earth mound and bushed before coming to rest, broken in two. Two passengers were killed while 78 other occupants were injured.
Probable cause:
Erroneous actions on part of the crew who, while landing in instrument meteorological conditions with one engine running, permitted the aircraft to touch down significantly to the right of the runway.
These actions were the result of following factors:
- The flight engineer inadvertently turned off the fuel booster pumps of the service tank while working the procedures for manual fuel transfer during the climb, which led to fuel starvation, all engines spooling down with the outer engines (#1 and #3) shutting down as well as loss of electrical power for 2:23 minutes due to loss of all three generators
- Failure by the crew to take use of all available possibilities to restore on-board systems after generator #2 was recovered and the APU spooled up and was successfully connected
- Failure to comply with recommendations "flying with two engines inoperative" and "approach and landing with two engines inoperative"
- Lack of leadership and lack of management and distribution of responsibilities by the captain leading to independent but not always accurate actions by the other crew members as result of insufficient training in crew resource management
- A complex wind environment varying with heights which contributed to the deviation from the proper approach trajectory while the crew was flying on stand by instruments rather than regular instruments
- Insufficient training of the crew as a whole as well as each individual to act in emergency and complex scenarios
- The non-implementation of safety recommendations developed in earlier investigations to prevent the flight engineer inadvertently turn off the fuel booster pumps.
Final Report:

Crash of a Beechcraft 1900C-1 in Maputo

Date & Time: Dec 3, 2010 at 2340 LT
Type of aircraft:
Operator:
Registration:
C9-AUO
Survivors:
Yes
Schedule:
Nampula - Maputo
MSN:
UC-148
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The flight from Nampula was uneventful until the approach to Maputo. Due to bad weather conditions at destination, the crew was vectored to a holding pattern. After two circuits, the captain decided to start the descent despite ATC informed him about very poor conditions. At this time, the visibility was reduced due to the night, heavy rain falls, thunderstorm activity with turbulences and lightnings. On final approach to runway 23, the aircraft was too low and impacted ground short of runway in a slight nose-up attitude. Upon impact, the aircraft broke in two and came to rest in a field. All 17 occupants escaped with minor injuries and the aircraft was destroyed.

Crash of a Piper PA-46-350P Malibu Mirage off Destin: 3 killed

Date & Time: Nov 23, 2010 at 1930 LT
Registration:
N548C
Flight Type:
Survivors:
No
Schedule:
New Orleans – Destin
MSN:
46-36322
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
408
Captain / Total hours on type:
34.00
Aircraft flight hours:
761
Circumstances:
The instrument-rated pilot was executing a night instrument approach when the airplane impacted the water. The published approach minimums for the area navigation/global positioning system approach were 460-foot ceiling and one-mile visibility. Recorded air traffic control voice and radar data indicated that prior to the approach the pilot had turned to an approximately 180-degree heading and appeared to be heading in the direction of another airport. The controller reassigned the pilot a heading in order to intercept the final approach. The airplane was located in the water approximately 5,000 feet from the runway threshold. A postaccident examination of the airplane revealed that the left main landing gear was in the retracted position and the right main and nose landing gear were in the extended position. Examination of the left main landing gear actuator revealed no mechanical anomalies. The pilot had likely just commanded the landing gear to the down position and the landing gear was in transit. It is further possible that, as the gear was in transit, the airplane impacted the water in a left-wing and nose-down attitude and the left gear was forced to a gear-up position.
Probable cause:
Controlled flight into water due to the pilot's improper descent below the published minimum descent altitude.
Final Report:

Crash of a Cessna 501 Citation I in Birmingham

Date & Time: Nov 19, 2010 at 1535 LT
Type of aircraft:
Registration:
G-VUEM
Flight Type:
Survivors:
Yes
Schedule:
Belfast - Birmingham
MSN:
501-0178
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
1785
Copilot / Total hours on type:
735
Circumstances:
The flight crew reported for duty at Liverpool Airport at 0845 hrs. Their original task was to fly to Belfast City Airport, collect a transplant organ, and take it to Cambridge Airport. However, on their arrival at Belfast the transfer was no longer required, so they were given a new task to fly to Belfast Aldergrove Airport and collect an organ to carry to Birmingham Airport. The aircraft departed Belfast Aldergrove at 1450 hrs with the co-pilot as pilot flying. The flight was uneventful and the aircraft was given a radar vector to intercept the ILS for a straight-in approach to Runway 15 at Birmingham. The Runway 15 ILS course is 149°M. The autopilot was engaged and the aircraft was flying on a track of 135°M, 13 nm from the touchdown zone and at a groundspeed of 254 kt, when it crossed the localiser centreline. The aircraft then turned right onto a corrective track but once again passed through the localiser course. Further corrections were made and the aircraft passed through the localiser once more before becoming established at 5 nm. The co-pilot later reported that, because the autopilot was not capturing the localiser, he had disconnected it and flown the approach manually. When the aircraft was at 10 nm, the radar controller broadcast a message advising of the presence of a fog bank on final approach and giving RVRs of 1,400 m at touchdown and in excess of 1,500 m at both the mid-point and stop end. The airfield was sighted by the commander during the approach but not by the co-pilot. A handover to the tower frequency was made at around 8 nm. When the aircraft was at 6 nm, landing clearance was given and acknowledged. The tower controller then advised the aircraft that there was a fog bank over the airfield boundary, together with the information that the touchdown RVR was 1,400 m. The commander responded, saying: “WE’VE GOT ONE END OF THE RUNWAY”. The aircraft was correctly on the localiser and the glideslope at 4 nm. The Decision Altitude (DA) of 503 feet amsl (200 feet aal) for the approach was written on a bug card mounted centrally above the glare shield. Both pilots recollected that the Standard Operating Procedure (SOP) calls of “500 above” and “100 above” DA were made by the commander. However, neither pilot could recall a call of ‘decision’ or ‘go-around’ being made. At between 1.1 nm and 0.9 nm, and 400 feet to 300 feet aal, the aircraft turned slightly to the right, onto a track of 152°M. This track was maintained until the aircraft struck the glideslope antenna to the right of the runway some 30 seconds later (see Figure 3, page 11). The aircraft came to rest in an upright position on the grass with a fire on the left side. The co-pilot evacuated through the main cabin door, which is located on the left side of the fuselage, and suffered flash burns as he passed through the fire. The commander was trapped in the cockpit for a time.
Probable cause:
The co-pilot’s task of flying the approach would have become increasingly demanding as the aircraft descended and it is probable that his attention was fully absorbed by this. This was confirmed by his erroneous perception that the aircraft was in IMC from below 2,000 feet amsl. The co-pilot reported that during the final stages of the approach, when he noticed he had lost the localiser indication, he had asked the commander whether he should go around. The response he reported he heard of “no, go left” was not what he had expected, and may correspond to the time from which no further control inputs were made. The commander could not recall having given any instructions to the co-pilot after the ‘100 feet above’ call. It is likely that the crew commenced the approach with an expectation that it would be completed visually. However, the weather conditions were unusual and the aircraft entered IMC unexpectedly, late in the approach. As an aircraft gets closer to a runway the localiser and glideslope indications become increasingly sensitive and small corrections have a relatively large effect. The task for the flying pilot becomes more demanding and the role of the monitoring pilot has greater significance. A successful outcome relies on effective crew co-ordination, based on clear SOPs. The monitoring of this approach broke down in the latter stages and the crucial ‘decision’ call was missed, which led to the aircraft’s descent below minima.
Final Report:

Crash of a Lockheed C-130H-30 Hercules in Paris

Date & Time: Nov 19, 2010 at 0900 LT
Type of aircraft:
Operator:
Registration:
7T-WHA
Flight Type:
Survivors:
Yes
Schedule:
Boufarik - Paris-Le Bourget
MSN:
4997
YOM:
1984
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing on runway 07 at Le Bourget Airport, the left main gear collapsed. The aircraft veered off runway to the left and came to rest. All 9 occupants evacuated safely while the aircraft was damaged beyond repair and withdrawn from use in LBG.
Probable cause:
Left main gear collapsed upon landing for unknown reasons.

Crash of a Lockheed C-130H Hercules in Sanaa

Date & Time: Nov 18, 2010
Type of aircraft:
Operator:
Registration:
7O-ADD
Flight Type:
Survivors:
Yes
MSN:
4827
YOM:
1979
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Sanaa Airport, the four engine aircraft veered off runway and came to rest, bursting into flames. All occupants escaped uninjured. The fire was quickly extinguished but the aircraft was damaged beyond repair.

Crash of a Learjet 25B in Portland

Date & Time: Nov 17, 2010 at 1553 LT
Type of aircraft:
Operator:
Registration:
N25PJ
Flight Type:
Survivors:
Yes
Schedule:
Boise - Portland
MSN:
25-111
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6000
Copilot / Total flying hours:
652
Copilot / Total hours on type:
10
Aircraft flight hours:
8453
Circumstances:
The airplane was flying a VOR/DME-C approach that was on an oblique course about 40 degrees to the runway 30 centerline; the wind conditions produced an 8-knot tailwind for landing on runway 30. Despite the tailwind, the captain elected to land on the 6,600-foot-long runway instead of circling to land with a headwind. Moderate to heavy rain had been falling for the past hour, and the runway was wet. The crew said that the airplane was flown at the prescribed airspeed (Vref) for its weight with the wing flaps fully extended on final approach, and that they touched down just beyond the touchdown zone. The captain said that he extended the wings' spoilers immediately after touchdown. He tested the brakes and noted normal brake pedal pressure. However, during rollout, he noted a lack of deceleration and applied more brake pressure, with no discernible deceleration. The airplane's optional thrust reversers had been previously rendered non-operational by company maintenance personnel and were therefore not functional. The captain stated that he thought about performing a go-around but believed that insufficient runway remained to ensure a safe takeoff. While trying to stop, he did not activate the emergency brakes (which would have bypassed the anti-skid system) because he thought that there was insufficient time, and he was preoccupied with maintaining control of the airplane. He asked the first officer to apply braking with him, and together the crew continued applying brake pedal pressure; however, when the airplane was about 2,000 feet from the runway's end, it was still traveling about 100 knots. As the airplane rolled off the departure end on runway 30, which was wet, both pilots estimated that the airplane was still travelling between 85 and 90 knots. The airplane traveled 618 feet through a rain-soaked grassy runway safety area before encountering a drainage swale that collapsed the nose gear. As the airplane was traversing the soft, wet field, its wheels partially sank into the ground. While decelerating, soil impacted the landing gear wheels and struts where wiring to the antiskid brake system was located. The crew said that there were no indications on any cockpit annunciator light of a system failure or malfunction; however, after the airplane came to a stop they observed that the annunciator light associated with the antiskid system for the No. 2 wheel was illuminated (indicating a system failure). The other three annunciator lights (one for each wheel) were not illuminated. During the approach, the first officer had completed the landing data card by using a company-developed quick reference card. The quick reference card’s chart, which contained some data consistent with the landing charts in the Airplane Flight Manual (AFM), did not have correction factors for tailwind conditions, whereas the charts in the AFM do contain corrective factors for tailwind conditions. The landing data prepared by the first officer indicated that 3,240 feet was required to stop the airplane on a dry runway in zero wind conditions, with a wet correction factor increasing stopping distance to 4,538 feet. The Vref speed was listed as 127 knots for their landing weight of 11,000 pounds, and the first officer’s verbal and written statements noted that they crossed the runway threshold at 125 knots. During the investigation, Bombardier Lear calculated the wet stopping distances with an 8-knot tailwind as 5,110 feet. The touchdown zone for runway 30 is 1,000 feet from the approach end. The crew’s estimate of their touchdown location on the runway is about 1,200 feet from the approach end, yielding a remaining runway of 5,400 feet. On-duty controllers in the tower watched the landing and said that the airplane touched down in front of the tower at a taxiway intersection that is 1,881 feet from the approach end, which would leave about 4,520 feet of runway to stop the airplane. The controllers observed water spraying off the airplane’s main landing gear just after touchdown. Post accident testing indicated that the brake system, including the brake wear, was within limits, with no anomalies found. No evidence of tire failure was noted. The antiskid system was removed from the airplane for functional tests. The control box and the left and right control valves tested within specifications. The four wheel speed sensors met the electrical resistance specification. For units 1, 2 and 3, the output voltages exceeded the minimum specified voltages for each of the listed frequencies. Unit 4 was frozen and could not be rotated and thus could not be tested. Sensors 1 and 2 exceeded the specified 15% maximum to minimum voltage variation limit. Sensor 3 was within the limit and 4 could not be tested. Based on all the evidence, it is likely that the airplane touched down on the water-contaminated runway beyond the touchdown zone, at a point with about 600 feet less remaining runway than the performance charts indicated that the airplane required for the wet conditions. Since a reverted rubber hydroplaning condition typically follows an encounter with dynamic hydroplaning, the reverted rubber signatures on the No. 2 tire indicate that the airplane encountered dynamic hydroplaning shortly after touchdown, and the left main gear wheel speed sensor anomalies allowed the left tires to progress to reverted rubber hydroplaning. This, along with postaccident testing, indicates that the anti-skid system was not performing optimally and, in concert with the hydroplaning conditions, significantly contributed to the lack of deceleration during the braking attempts.
Probable cause:
The failure of the flight crew to stop the airplane on the runway due to the flying pilot’s failure to attain the proper touchdown point. Contributing to the accident was an anti-skid system that was not performing optimally, which allowed the airplane to encounter reverted rubber hydroplaning, and the company-developed quick reference landing distance chart that did not provide correction factors related to tailwind conditions.
Final Report:

Crash of a Swearingen SA227AC Metro III in Andahuaylas

Date & Time: Nov 13, 2010 at 1602 LT
Type of aircraft:
Operator:
Registration:
N781C
Survivors:
Yes
Schedule:
Huaraz - Andahuaylas
MSN:
AC-535
YOM:
1982
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6301
Captain / Total hours on type:
2615.00
Copilot / Total flying hours:
3253
Copilot / Total hours on type:
737
Aircraft flight hours:
27889
Aircraft flight cycles:
37163
Circumstances:
Following an uneventful flight, the twine engine aircraft approached Andahuaylas Airport and landed normally on runway 03. After touchdown, while decelerating to a speed of about 40 knots, the aircraft started to deviate to the left. The crew counteracted but the aircraft continued to the left, veered off runway, rolled through a grassy and eventually came down a four meters high embankment before coming to rest. While all 19 occupants escaped uninjured, the aircraft was damaged beyond repair.
Probable cause:
It appears that the loss of directional control after touchdown was caused by the failure of the brake systems. The aircraft had already several technical problems with its brake systems previous to the flight, and maintenance was performed by technicians the day before the accident. For unknown reasons, the problem was resolved but no feedback or troubleshooting was performed on part of the technicians or the crew. The Captain was aware of the problem and took the decision to complete the flight despite the risk the problem may persist or happen again.
Final Report: