French pilot: 6 months suspended sentence in accident case

A French pilot was received a six months suspended sentence for causing an accident in Pau, France that killed one man on the ground.

On January 25, 2007 a Fokker 100 passenger jet, operated by French carrier Régional, overshot the end of the runway at Pau following an aborted takeoff. Upon crossing a road, the left main landing gear struck the cabin of a truck, killing the driver.

The BEA investigation concluded that “the accident resulted from a loss of control caused by the presence of ice contamination on the surface of the wings associated with insufficient consideration of the weather during the stopover, and by the rapid rotation pitch, a reflex reaction to a flight of birds.” BEA also noted as one of the contributing factors, that there was “limited awareness within the [French] aviation community regarding the risks associated with the icing on the ground and changes in the performance of the aircraft involved in this phenomenon”.

The pilot in command of the flight was being charged with  homicide and unintentional injuries. A criminal court in Pau decided on a six months suspended sentence and a 20.000 Euro fine for the airline.

Source: Sud-Ouest (3-1-2012)

More information:

• ASN Accident description

Brakes applied on takeoff led to fatal Yaroslavl Yak-42 accident

Investigators of the Russian Interstate Aviation Commission (MAK) presented the findings of their investigation into the fatal Yak-42 accident at Yaroslavl in September 2011.

On September 7, 2011 a Yak Service Yak-42 passenger jet crashed on takeoff from Yaroslavl-Tunoshna Airport (IAR), Russia, killing 44. The airplane carried members of the Lokomotiv Yaroslavl ice hockey team for a match in Minsk.
It was determined that:

• the crew calculated the V1 speed to be 190 km/h; however this was incorrect as it should have been 220 km/h;
• the copilot had medical issues, he had leg coordination disturbances and the deep sensibility disorders of lower extremities. The medicine Phenobarbital, which has a negative impact on the nervous system, was found in his blood which degraded his performance;
• while the captain had over 1300 hours of experience flying Yak-42 aircraft, he flew the smaller Yak-40 aircraft before that and had more experience in those aircraft. The same applied to the copilot. Both aircraft have a different method of braking and the captain or copilot (it could not be concluded who pushed the brakes) probably held his feet on the pedals during takeoff in a similar manner that he had used on the Yak-40. In the accident he inadvertently activated the brakes while pulling on the controls to lift the nose for takeoff.

The investigators established that there were at least four contributing factors, including a lack of pilot training, the absence of control over the crew’s preparation for flight, the pilots’ failure to follow standard takeoff procedures and poor coordination between the crew during the takeoff.

 

Russian Tu-134 accident caused by poor decision making in below-minima weather conditions

The Tu-134 broke up. (photo: Ministry of Emergency Situations)

The Russian Interstate Aviation Committee (IAC) published the final report of their investigation into the fatal accident involving a Tupolev 134 jetliner at Petrozavodsk, Russia, blaming poor decision making in below-minima weather conditions.

On June 20, 2011 a Tu-134 operated by RusAir on behalf of RusLine, crashed on final approach to Petrozavodsk Airport (PES). The Tupolev struck trees and crash-landed on a highway while on final approach to runway 01. Forty-seven occupants died in the accident; five survived.

The investigators concluded that the airplane flew an approach in conditions worse than weather minimums for the airfield and that the crew failed decide to go-around. Instead the airplane descended below the minimum safe altitude in the absence of visual contact with approaching lighting and landmarks, which led to contact with trees and the ground in controlled flight.
Contributing factors were:

• Poor interaction of the crew and poor crew resource management (CRM) from the commander of the flight during the approach. The pilot subordinated himself to the navigator causing the co-pilot to be effectively excluded from decisions;
• The use during the flight of a navigator in a light level of alcoholic intoxication;
• Incorrect weather forecast with regards to height of the cloud base, visibility and severe weather – fog;
• The use of navigation equipment that used satellite navigation to determine the aircrafts position, which was in violation of the Flight Manual Supplement for the Tu-134.

 

More info:

• ASN Accident description
• Final report (PDF, in Russian)

 

NTSB: Fatal Alaska accident involving Ted Stevens caused by pilot’s temporary unresponsiveness

The airplane wreckage (photo: NTSB)

The U.S. NTSB concluded their investigation into the cause of the August 2010 fatal accident involving a DHC-3T Turbine Otter in Alaska.  Former U.S. Senator Ted Stevens was among the five fatalities. 

On August 9, 2010, the single-engine, turbine-powered, amphibious float-equipped de Havilland DHC-3T airplane, N455A, impacted mountainous, tree-covered terrain about 10 nautical miles northeast of Aleknagik, Alaska. The airline transport pilot and four passengers received fatal injuries, and four passengers received serious injuries.
The flight was operated by GCI Communication Corp. from a GCI-owned private lodge on the shore of Lake Nerka and was en route to a remote sport fishing camp about 52 nm southeast on the Nushagak River.

Marginal visual flight rules were reported at Dillingham Airport, Dillingham, Alaska, about 18 nm south of the accident site.

The National Transportation Safety Board determined that the probable cause of this accident was the pilot’s temporary unresponsiveness for reasons that could not be established from the available information. Contributing to the investigation’s inability to determine exactly what occurred in the final minutes of the flight was the lack of a cockpit recorder system with the ability to capture audio, images, and parametric data.

The NTSB noted that fatigue, stress or a  medical condition could have been a factor in the pilot’s temporary unresponsiveness.  However, there is insufficient evidence to determine whether these factors played a role in the accident.

More information:

• NTSB Accident Synopsis
• NTSB Board meeting presentations
• ASN Accident Description

NTSB: decision to attempt a go-around late in the landing roll with insufficient runway remaining caused fatal BAe 125 accident in Owatonna

The U.S. National Transportation Safety Board (NTSB) determined that the probable cause of the 2008 BAe-125 plane crash at Owatonna Degner Regional Airport, Owatonna, Minnesota, was the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining.

Contributing to the accident were the pilots’ poor crew coordination and lack of cockpit discipline; fatigue, which likely impaired both pilots’ performance; and the failure of the Federal Aviation Administration (FAA) to require crew resource management training and standard operating procedures for Part 135 operators.

On July 31, 2008, East Coast Jets flight 81, a BAe 125-800A registered N818MV, crashed while attempting a go-around after touchdown and during the landing rollout at Owatonna Degner Regional Airport. The flight was a nonscheduled passenger flight. An instrument flight rules flight plan had been filed and activated; however, it was cancelled before the landing. Visual meteorological conditions prevailed at the time of the accident. The two pilots and six passengers were killed.

The following safety recommendations were issued to the FAA:

1. Require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted.
2. Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers’ Aircraft Flight Manuals asked for in Safety Recommendation [1]  into their manuals and training.
3. Require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures.
4. Require principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions.
5. Require manufacturers and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with the actual flap position, rather than just stating, “set” or “as required.”
6. Work with the National Weather Service to revise Advisory Circular 00-24B, “Thunderstorms,” by including explanations of the terms used to describe severe thunderstorms, such as “bow echo,” “derecho,” and “mesoscale convective system.”
7. Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia.
8. Require 14 Code of Federal Regulations Part 135 and 91 subpart K pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and symptoms, and effective strategies to manage fatigue and performance during operations.
9. Review the policy standards for all common sleep-related conditions, including insomnia, and revise them in accordance with current scientific evidence to establish standards under which pilots can be effectively treated for common sleep disorders while retaining their medical certification.
10. Increase the education and training of physicians and pilots on common sleep disorders, including insomnia, emphasizing the need for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions.
11. Actively pursue with aircraft and avionics manufacturers the development of technology to reduce or prevent runway excursions and, once it becomes available, require that the technology be installed.
12. Inform operators of airplanes that have wet runway landing distance data based on the British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X1591 that the data contained in the Aircraft Flight Manuals (and/or performance supplemental materials) may underestimate the landing distance required to land on wet, ungrooved runways and work with industry to provide guidance to these operators on how to conduct landing distance assessments when landing on such runways.
13. Require that 14 Code of Federal Regulations Part 135 pilot‑in‑command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted.
14. Require Part 121, 135, and 91 subpart K operators to ensure that terrain awareness and warning system-equipped aircraft in their fleet have the current terrain database installed.

More information:

• ASN Accident Description
• NTSB Board meeting documents
• NTSB Public Docket

Accident: Iran Air Boeing 727 crashes near Urumiyeh

An Iran Air Boeing 727 passenger jet was damaged beyond repair in an accident about 8 km from Urmia (Orumiyeh) Airport (OMH), Iran. About seventy occupants were reportedly killed.

Iran Air flight IR277 departed Tehran-Mehrabad Airport (THR) at 18:15 on a domestic flight to Urmia (Orumiyeh) Airport (OMH). The flight was delayed over two hours due to severe weather at the destination.

There were 93 passengers and twelve crew members on board. The Deputy Minister of Roads and Transportation indicated that the accident occurred during a forced landing outside the airport. A spokesperson from the Red Crescent organisation said 70 people were killed in the accident.

Update Jan 10, 05:20 UTC: Latest media reports indicate that 77 people were killed, 26 people were injured and two missing.

Update Jan 10, 20:25 UTC: Latest media reports (IRAN) confirm that 77 people were killed.

Weather reported about the time of the accident (16:15 UTC / 19:45 local) was:

OITR 091600Z 26004KT 0800 SN SCT015 SCT020 OVC060 00/00 Q1016=

This METAR report from 16:00 UTC indicates:

• Wind 260 degrees at 4 knots
• Visibility 800 m in snow
• Scattered clouds 1,500 ft
• Scattered clouds 2,000 ft.
• Overcast 6,000 ft.
• Temperature 0°C
• Dew point 0°C
• Pressure 1016 hPa

According to local aviation sources in Iran, the airplane involved in the accident was EP-IRP. This has not yet been confirmed by CAO officials. EP-IRP is a Boeing 727-286 that was delivered to the airline in 1974.

Update Jan 10, 20:25 UTC: The registration has been confirmed based on photographs of the accident scene

According to Aviation Safety Network data, this accident is the 10th worst accident in Iran.  The previous fatal accident involving a Boeing 727 on a passenger service, happened about six years ago, in December 2003.

More information:

http://aviation-safety.net/database/record.php?id=20110109-0

Report: Pilot’s non-adherence to procedures causes fatal USAF C-17 crash

The USAF Accident Investigation Board reported that the July 2010 accident involving a C-17 Globemaster III was caused by “pilot error”.

The McDonnell Douglas C-17A Globemaster III transport plane was operated by the US Air Force 517AS/3rd Wing and was going to practice maneuvers for the upcoming  Arctic Thunder Air Show at Anchorage-Elmendorf AFB, AK (EDF).

The airplane executed a takeoff from runway 06. After the initial climb out and left turn, the pilot executed an aggressive right turn. As the aircraft banked, the stall warning system activated to alert the crew of an impending stall. Instead of implementing stall recovery procedures, the pilot continued the turn as planned, and the aircraft entered a stall from which recovery was not possible. Although the pilot eventually attempted to recover the aircraft, he employed incorrect procedures, and there was not sufficient altitude to regain controlled flight.The aircraft impacted wooded terrain northwest of the airfield, damaged a portion of the Alaskan Railroad, and was destroyed.

The board president found clear and convincing evidence that the cause of the mishap was pilot error. The pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. Furthermore, the copilot and safety observer did not realize the developing dangerous situation and failed to make appropriate inputs. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items. The board also found channelized attention, overconfidence, expectancy, misplaced motivation, procedural guidance, and program oversight substantially contributed to the mishap.

Report: Fatal Grumman G-21 crash in Canada due to VFR flight into instrument weather

The Transportation Safety Board of Canada (TSB) issued their final report of the investigation into the cause of a CFIT accident involving a Gruman G-21 amphibious plane in November 2008, citing VFR flight into instrument meteorological conditions (IMC).

At about 10:13 Pacific Standard Time, the amphibious Grumman G-21A (registration C-FPCK), operated by Pacific Coastal Airlines, departed from the water aerodrome at the south terminal of the Vancouver International Airport, British Columbia, with one pilot and seven passengers for a flight to Powell River, British Columbia. Approximately 19 minutes later, the aircraft crashed in dense fog on South Thormanby Island, about halfway between Vancouver and Powell River. Local searchers located a seriously injured passenger on the eastern shoreline of the island at about 14:00. The aircraft was located about 30 minutes later, on a peak near Spyglass Hill, British Columbia. The pilot and the six other passengers were fatally injured, and the aircraft was destroyed by impact and post-crash fire. The emergency locator transmitter was destroyed and did not transmit.

The investigators concluded the following:

Findings as to causes and contributing factors:

1. The pilot likely departed and continued flight in conditions that were below visual flight rules (VFR) weather minima.
2. The pilot continued his VFR flight into instrument meteorological conditions (IMC), and did not recognize his proximity to terrain until seconds before colliding with Thormanby Island, British Columbia.
3. The indication of a marginal weather improvement at Powell River, British Columbia, and incorrect information from Merry Island, British Columbia, may have contributed to the pilot’s conclusion that weather along the route would be sufficient for a low-level flight.

Findings as to risk:

1. The reliance on a single VHF-AM radio for commercial operations, particularly in congested airspace, increases the risk that important information is not received.
2. Flights conducted at low altitude greatly decrease VHF radio reception range, making it difficult to obtain route-related information that could affect safety.
3. The lack of pilot decision making (PDM) training for VFR air taxi operators exposes pilots and passengers to increased risk when faced with adverse weather conditions.
4. Some operators and pilots intentionally skirt VFR weather minima, which increases risk to passengers and pilots travelling on air taxi aircraft in adverse weather conditions.
5. Customers who apply pressure to complete flights despite adverse weather can negatively influence pilot and operator decisions.
6. Incremental growth in Pacific Coastal’s support to Kiewit did not trigger further risk analysis by either company. As a result, pilots and passengers were exposed to increased risks that went undetected.
7. Transport Canada’s guidance on risk assessment does not address incremental growth for air operators. As a result, there is increased risk that operators will not conduct the appropriate risk analysis as their operation grows.
8. Previous discussions between Pacific Coastal and the pilot about his weather decision making were not documented under the company’s safety management system (SMS). If hazards are not documented, a formal risk analysis may not be prompted to define and mitigate the risk.
9. There were no company procedures or decision aids (that is, decision tree, second pilot input, dispatcher co-authority) in place to augment a pilot’s decision to depart.
10. Because the aircraft’s emergency locator transmitter (ELT) failed to operate after the crash, determining that a crash had occurred and locating the aircraft were delayed.
11. On a number of flights, pilots on the Vancouver-Toba Inlet route, British Columbia, departed over maximum gross weight due to incorrectly calculated weight and balances. Risks to pilots and passengers are increased when the aircraft is operating outside approved limits.
12. The over-reliance on global positioning system (GPS) in conditions of low visibility and ceilings presents a significant safety risk to pilots and passengers.

Lack of rules requiring dissemination of wind condition data and pilot’s insufficient rudder control cited as probable cause of 2008 Denver runway accident

Continental Flight 1404

The National Transportation Safety Board (NTSB) determined that the probable cause of the 2008 Continental Airlines flight 1404 runway excursion accident was the captain’s cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the aircraft departed the runway, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.

Contributing to the accident was the air traffic control system that did not require or facilitate the dissemination of key available wind information to air traffic controllers and pilots, and inadequate cross wind training in the airline industry due to deficient simulator wind gust modeling.

On December 20, 2008, Continental Airlines flight 1404, a Boeing 737-500, veered off the left side of runway 34R during a takeoff from Denver International Airport. As a result, the captain initiated a rejected takeoff and the airplane came to rest between runways 34R and 34L. There was a post-crash fire. All 110 passengers and 5 crewmembers evacuated the airplane immediately after it came to rest. The captain and five passengers were seriously injured.

At the time of the accident, mountain wave and downsloping wind conditions existed in the Denver area and the strong localized winds associated with these conditions resulted in pulses of strong wind gusts at the surface that posed a threat to operations at Denver International Airport.

As a result of this accident the NTSB issued 14 recommendations to the Federal Aviation Administration regarding mountain waves, wind dissemination to flightcrews, runway selection, pilot training for crosswind takeoffs, and crashworthiness.

More information: Report NTSB/AAR-10/04

Airport safety recommendations after Indonesian B737 runway excursion accident

Wreckage of the Boeing 737 after it came to rest in an area of shallow muddy water surrounded by mangrove vegetation. Photo: NTSC

The Indonesian National Transportation Safety Committee (NTSC) issued their preliminary report regarding the runway excursion accident involving a Boeing 737. Seven safety recommendations were issued addressing various aspects of airport safety.

On April 13, 2010 a Boeing 737-322 passenger plane, registered PK-MDE, sustained substantial damage in a runway excursion accident at Manokwari-Rendani Airport (MKW/WASR), Indonesia. All 103 passengers and seven crew members survived but ten sustained serious injuries.
Merpati Flight MNA836 operated on a scheduled flight from Sorong-Dominique Edward Osok Airport (SOQ/WAXX). Departure was delayed for almost three hours due to heavy rain over Manokwari.
On approach Rendani Radio informed the crew that the weather was continuous slight rain, visibility 3 kilometers, cloud overcast with cumulus-stratocumulus at 1,400 feet, temperature 24 degrees Celsius, QNH 1012 hectopascals.
At 10:54 the crew reported that they were on final for runway 35. The controller informed them that the wind was calm, runway condition was wet and clear.
The crew read back the wind condition and that the runway was clear, but did not mention the wet runway condition.
The aircraft was observed to make a normal touchdown on the runway, about 120 meters from the approach end of runway 35. Witnesses on the ground and on board reported that engine reverser sound was not heard during landing roll.
During the landing roll, the aircraft veered to the left about 140 meters from the end of runway 35, then overran the departure end of runway 35. It came to a stop 205 meters beyond the end of the runway in a narrow river; the Rendani River.
The airport rescue and fire fighting unit was immediately deployed to assist the post-crash evacuation. Due to the steep terrain 155 meters from the end of runway 35, the rescuers had to turn back and use the airport’s main road to reach the aircraft. The accident site was in an area of shallow muddy water surrounded by mangrove vegetation.

Seven safety recommendations were issued:

1) The Directorate General Civil of Aviation (DGCA) should ensure that Merpati Nusantara Airlines Operational Specifications and other technical and operational safety requirements are met.

2) DGCA should urgently review the Rendani Airport, Manokwari runway complex, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

3) DGCA should urgently review all airports involving Part 121 and 135 operations, to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in ICAO Annex 14.

4) DGCA should urgently ensure that Indonesian airports equipped with visual approach slope guidance systems, maintain the equipment to a serviceable standard.

5) DGCA should review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they a) meet the minimum requirements, including timeliness, specified in ICAO Annex 14; and b) meet the requirements to cover the area up to 5 NM (8 Km) from the airport perimeter.

6) Merpati should review its technical and operational safety requirements to ensure they are implemented.

7) Merpati should review equipment used by airport Rescue and Fire Fighting Services at airports in its network, to ensure that they meet the minimum requirements for Boeing 737 aircraft.