Progress report: TSB Canada classifies Resolute Bay Boeing 737 accident as CFIT

January 5, 2012

In a progress report of their investigation into a fatal Boeing 737 accident at Resolute Bay, the Transportation Safety Board of Canada currently classified the accident as a Controlled Flight Into Terrain (CFIT) occurence.

On 20 August 2011, a First Air Boeing 737-210C aircraft (registration C-GNWN) was being flown as a charter flight from Yellowknife, North West Territories, to Resolute Bay, Nunavut.  At 11:42, during the approach to Runway 35T, First Air Flight 6560 impacted a hill at 396 feet above sea level (asl) and about 1 nautical mile east of the midpoint of the Resolute Bay Airport runway which, itself, is at 215 feet asl. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and the four crew members suffered fatal injuries. Three passengers suffered serious injuries.

The investigators have complete the field phase of the  investigation. With regards to the weather, it was reported that in the hours before the accident, the weather in Resolute Bay was variable with fluctuations in visibility and cloud ceiling. Forty minutes before the accident, the visibility was 10 miles in light drizzle with an overcast ceiling at 700 feet above ground level (agl). A weather observation taken shortly after the accident, reported visibility of 5 miles in light drizzle and mist with an overcast ceiling of 300 feet agl.

The weather conditions required the crew to conduct an instrument approach using the aircraft flight and navigation instruments. The crew planned to conduct an instrument landing system (ILS) approach to Runway 35T. This instrument approach provides guidance down to weather minimums of 12 mile visibility and a ceiling of 200 feet agl.

The crew initiated a go-around 2 seconds before impact. At this time, the flaps were set to position 40, the landing gear was down and locked, the speed was 157 knots and the final landing checklist was complete.

Another aircraft successfully completed an ILS approach to Runway 35T approximately 20 minutes after the accident. NAV CANADA conducted a flight check of the ground based ILS equipment on 22 August 2011; it was reported as serviceable.

The technical examination of the aircraft at the accident site revealed no pre-impactproblems. Analysis of the flight data recorder information and examination of the engines at the site indicate the engines were operating and developing considerable power at the time of the accident. Analysis of the aircraft flight and navigational instruments is ongoing.

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Preliminary report issued on Maldives DHC-6 training flight accident

October 16, 2011

The Maldives Accident Investigation Coordinating Committe published a preliminary investigation report regarding the July 11, 2011 accident involving a DHC-6 Twin Otter.

The float-equipped de Havilland Canada DHC-6 Twin Otter sustained substantial damage in a heavy landing in Biyaadhoo Training Lagoon, Maldives. The two pilots on board were not injured. The airplane was used for an annual re-current training flight. Departure time at Malé (MLE) was 08:20 and the flight had to be back before 09:30 because both crew members were scheduled to do a commercial flight at that time.
During the training five landings and take-offs were made simulating different conditions of flight. All these landings and take-offs were made inside the lagoon except the last landing where the crew decided to land on open water outside the lagoon. The crew were simulating a tail wind/single engine landing.
As per the crew, the aircraft initial touch down was smooth. However, they stroke a wave which made the aircraft bounce foe about 20 feet. With the low power aircraft hit the water again with great impact, resulting multiple float attachments to break. Both front and main spreader bars broke and floats rose up, twisted and hitting the bottom engine cowlings. Propeller cuts were found on front of both floats. Also, the flaps as well as the flap selectors were found on the zero position.

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Report: Unstabilized approach preceded Colombian ERJ-145 runway excursion

September 26, 2011

The Colombian aircraft accident investigation committee concluded that the an ERJ-145 runway excursion at Mitú, Colombia occurred because the flight crew continued to land following an unstabilzed approach.

On May 5, 2010. an Embraer ERJ145, registered HK-4536, sustained substantial damage in a runway excursion accident at Mitú-Fabio Alberto León Bentley Airport (MVP), Colombia. There were no fatalities and there was no fire.
SATENA flight NSE-9634 had departed Villavicencio-La Vanguardia Airport (VVC) on a domestic flight to Mitú. The airplane could not be stopped on the runway when it landed on runway 20. It overran into a down sloping field, causing the undercarriage to collapse. The airplane came to rest 167 metres past the runway threshold and 4 metres below runway elevation.

The Board of Inquiry found that the probable cause of the accident was the execution of a landing on runway 20 at Mitu, following a destabilized approach especially with respect to deviations of height and speed when crossing the runway threshold, and the EGPWS alarm sound, which caused the aircraft to exceed the available runway. Additionally, the crew used  faulty techniques for landing on short and wet runways. Contributing to the accident was the lack of planning to carry out and complete the published instrument approach procedure for runway 20 and the deviation from standard operating procedures of the company.

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

September 19, 2011

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.


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Report: CIAIAC publishes final report on fatal MD-82 takeoff accident Madrid, Spain

August 3, 2011

After almost three years the Spanish investigators of the Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC) have published the final report of their investigation into the cause of the fatal accident involving a Spanair MD-82 at Madrid, Spain. 

The MD-82 passenger plane, registered EC-HFP, was destroyed when it crashed on takeoff at Madrid-Barajas Airport (MAD), Spain on August 20, 2008. Of the aircraft’s occupants, 154 were killed, including all six crew members, and 18 were seriously injured. The MD-82 aircraft operated Spanair flight JKK5022 from Madrid-Barajas (MAD) to Gran Canaria (LPA).

The CIAIAC has determined that the accident occurred because *):

The crew lost control of the aircraft as a result of a stall immediately after takeoff, when the plane was not configured correctly, with the flaps / slats not being deployed, following a series of failures and omissions, with the absence of a warning of the incorrect takeoff setting.
The crew did not identify the lack of warnings nor correct the situation after takeoff –momentarily retarding engine power levers, increasing the pitch angle and failure to correct the roll– deteriorating the flight conditions.
The crew did not detect the configuration error by not properly using the checklists containing items to select and check the position of flaps / slats in the work of flight preparation, namely:

  • Failure to conduct the action of selecting flaps / slats (in the “After Start Checklist”);
  • No cross-checking was made of the position of the lever and the status indicator lights for flaps and slats during the “After Start” checklist;
  • Omission to check the flaps and slats under “Take Off Briefing” in the taxi checklist;
  • The visual inspection of the position of the flaps and slats at the point “Final Items” of the “Take Off Imminent” checks was not made, as shown by the instruments of the cockpit.

As contributory factors CIAIAC determined:

  • The absence of a notice of the incorrect takeoff configuration because the TOWS did not work and therefore did not alert the crew that the takeoff configuration of the aircraft was inappropriate. It was not possible to determine conclusively the cause why the TOWS system did not work.
  • Inadequate crew resource management (CRM), which did not prevent the diversion of procedures in the preparation of the flight.

*) The final report is currently available in Spanish. An English translation is being prepared by CIAIAC. In case of conflicting text, the Spanish text is valid.

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Report: Islander ditching following engine failure caused by overloading

May 20, 2011

The Dutch Safety Board published the results of their investigation into an accident involving a BN-2 Islander aircraft of Divi Divi Air in October 2009. 

The airplane suffered a right hand engine failure shortly after takeoff from Curacao on an inter-island flight to Bonaire. The pilot elected to continue to Bonaire on the remaining engine. Altitide could not be maintain and the airplane ditched off Bonaire. The pilot was killed in this accident.  The nine passengers escaped the airplane relatively unharmed and were picked up by boats nearby the crash site.

The investigation showed that the airplane was unable to maintain horizontal flight after one of the engines had failed, due to overloading. The airplane was overloaded by 9%. With the continuation of the flight under these circumstances the pilot took a completely unacceptable risk. Furthermore the Board has established  that Divi Divi Air used standard passengers weight that were too low.  A random audit revealed that the maximum takeoff ‐ and landing weights, were systematically exceeded.

The investigation also revealed that the Divi Divi Air management insufficiently supervised the safety of the flight operations of their airplanes. Also safety oversight conducted by the Netherlands Antilles Directorate of Aviation was limited. In this light, the Safety Board referred to the ICAO audit that was conducted in 2008. This audit revealed many deviations of the ICAO standards and regulations. The Board is concerned about safety oversight on civil aviation at Curacao.

The results of the investigation have resulted in recommendation of the Board to Divi Divi Air and the Minister of Traffic, Transportation and Spatial Planning of Curacao and the Governor of Bonaire.

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NTSB cites crew actions in ATR-42 cargo flight crash in Texas

April 27, 2011

The accident airplane (photo: FAA)

The crash of an ATR-42  cargo airplane while on approach to landing at Lubbock, Texas, was caused by the flight crew’s failure to maintain a safe airspeed, which put the plane into an aerodynamic stall at an altitude too low from which to recover, the NTSB determined.

Poor crew resource management, flawed decision-making and human fatigue were cited as contributing factors to the crash that left the captain seriously injured and the first officer with minor injuries.

On January 27, 2009, at 4:37 a.m. CST, an ATR 42-320 (N902FX) operating as Empire Airlines flight 8284 between Ft. Worth and Lubbock, was on an instrument approach when it crashed short of the runway. The airplane, which was registered to Federal Express Corporation (FedEx) and operated by Empire Airlines, Inc., was substantially damaged.

The aircraft, which had departed Ft. Worth about 84 minutes before the accident occurred, encountered icing conditions while en route to Lubbock. And although the airplane accumulated some ice during the flight that degraded its performance, the NTSB determined that the aircraft could have landed safely had the airspeed been maintained.

During the approach into Lubbock, at about 1400 feet above the ground and about 90 seconds from the runway, the captain indicated a flight control problem saying, “We have no flaps.” Although the crewmembers had been trained to perform a go-around and refer to a checklist if a flap problem occurred during an approach, the captain chose to continue the approach as he attempted to troubleshoot the flap anomaly while the first officer flew the plane. Neither flight crewmember adequately monitored the airspeed, which decayed to the extent that the stick shaker activated, which warned of an impending aerodynamic stall.

The captain continued the unstabilized approach even though he received additional stick shaker activations and an aural “pull up” warning from the terrain awareness and warning system (TAWS). At that point, the plane was descending at a rate of over 2,000 ft per minute.

Although procedures for responding to either the stick shaker or the TAWS warning require the immediate application of maximum engine power, the captain did not apply maximum power until 17 seconds after the TAWS warning. Seconds after maximum power was applied, the airplane entered an aerodynamic stall and crashed.

The NTSB also uncovered significant issues related to icing. Empire Airlines had dispatched the airplane into icing conditions that were outside the airplane’s certification envelope. Although this practice was not prohibited by the Federal Aviation Administration (FAA), the NTSB has longstanding concerns about operations in freezing drizzle/freezing rain and as a result of this investigation made a safety recommendation to address the issue.

Among the nine safety recommendations that the NTSB made to the FAA were:

  • improve crew resource management training to encourage first officers to more assertively voice their concerns and teach captains to develop a leadership style that supports first officer assertiveness;
  • prohibit operators of pneumatic boot-equipped airplanes from dispatching them into icing conditions that are outside of those that the airplane was certified for;
  • educate pilots and dispatch personnel on the dangers of flight in freezing precipitation;
  • develop a method to quickly communicate flight information regarding the number of persons aboard and the presence of hazardous materials to emergency responders;
  • provide guidance on monitoring and ensuring the operability of emergency response and mutual aid gates during winter operations;
  • require all operators of ATR 42 and ATR 72 series airplanes to be equipped with an aircraft performance monitoring system;
  • improve flight simulator fidelity to more accurately model aerodynamic degradations resulting from airframe ice accumulation and ensure that flight crews are trained on them;
  • and require all ATR 42 aircraft to be equipped with a flap asymmetry annunciator light.
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