Crash of an Ilyushin II-62M in Mashhad: 16 killed

Date & Time: Jul 25, 2009 at 1805 LT
Type of aircraft:
Operator:
Registration:
UP-I6208
Survivors:
Yes
Schedule:
Tehran - Mashhad
MSN:
19 51 5 2 5
YOM:
1989
Flight number:
IRX1525
Country:
Region:
Crew on board:
17
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
14200
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
8294
Copilot / Total hours on type:
1319
Aircraft flight hours:
13573
Aircraft flight cycles:
3987
Circumstances:
At July 24, 2009, Ilyushin aircraft, model IL-62M of DETA Airline with registration, UP-I6208 and flight IRX1525 of Aria Airline flight with 169 passengers from Mehrabad International Airport/ Tehran, and it has landed at 18:05 local time on RWY 13 L in Mashhad International Airport; then it has run off from end of the runway, without considerable reduction in aircraft speed and it collided with wall of the airport and it was stopped after approximately 185 m. The mentioned aircraft has been leased by Aria Airline as ACMI, according to contract No. 002/IL-62M/ACMI. Subsequently, the ground safety unit of the airport has attended in place of occurring accident, by breaking protective fences and barbed wires of the airport, and then they evacuated passengers and extinguished fire outside of aircraft by carrying out necessary actions. 16 people were killed, 11 crew members and five passengers. All other occupants were rescued, among them 30 were injured. Accident site inspection revealed that the aircraft position had coordinates N 36,218º E 59,666º, at a road in the vicinity of the aerodrome, 1km away from the RWY-31R threshold (130º MH or 133, 5º TH) of the Mashhad airport with the azimuth of 125º (true). Power line along the road was destroyed by the right aircraft wing. Wing fuel tanks of the right wing were damaged evidenced by fuel leaking. Main and emergency exits were open. An inflatable slide was dropped down from the port side. No evidences of fire on board and at the accident site were found. First tracks of intensive braking (black tire tracks) were found at the concrete at a distance of 550 m from the departure threshold of RWY31R. The track of the main gear wheels was going along the RWY in its left part, and diverging further to the right beyond the departure threshold. At about 100m away from the threshold at the end portion of the braking way, a net barrier was found (textile aerodrome emergency braking unit).The aircraft ran over the RWY when moving along the right side of the stop way, 300m long. Beyond the end of the RWY landing gear wheels track could be clearly seen passing over a rough partly grassed surface, and crossing a dirt road. At a distance of 100m from the RWY end, where the right gear crossed the road, a destroyed tire tube was found, which presumably belonged to the right gear front wheel. At a distance of 160m from the RWY end smashed approach lights were found, and after that point the gear wheel track started to diverge to the left from the RWY centerline. The front gear wheel track further merged with the left gear wheel track and extended joining the forward airframe track. At a distance of 320 m from the RWY end another line of broken approach lights were found. Airframe structures were found before the approach lights (along the aircraft way). From that point small aircraft structure pieces were found along the whole aircraft path. 40m past the destroyed approach lights line a ditch of 0,5…1m in depth was found (with an underground pipeline) which was crossing this area from the south to the north. The south-eastern part of the aerodrome was fenced with a brick wall of 2,5m high and 0,4m thick with a concrete strip foundation. It went along the RWY there. The aircraft collided with the fence at a distance of 820m from the departure threshold (520m past the stop way end) with a heading of 105 degrees. The fence was destroyed throughout 70m. Debris of the nose part of the airframe, cockpit, passenger seats, aircraft cabin parts were found behind the fence. Earlier aerodrome employees, police and medical services found at the site and evacuated crew bodies, as well as killed and injured passengers. After the collision with the fence the aircraft kept moving for 160 m with a heading of 105 degrees and came to a stop at the road.
Probable cause:
The following findings were identified:
- The crew was not trained &acquainted with flight conditions in the Iran territory with an Iranian instructor pilot and the operation unit of Aria Airline has acted so weak regarding those mentioned subjects.
- The approach speed of aircraft was higher than recommended available airport charts & aircraft weight, however it was controllable if the crew could proceed to land correctively.
- The crew had not done correct procedure according to the aircraft Standard Operation Procedure (SOP) to use related check lists. (Descend-Approach-Landing)
- There was lack of precise coordination between flight crew on their self responsibility during the approach and landing.
- The flight crew did not pay attention to EGPWS warning, and did not take corrective action.
- The crew did not use engine reverser and spoiler systems correctly to reduce aircraft speed during the landing and consequently it caused to loose long Runway distance.
- The flight crew had not good English language proficiency. And they were poor in England language conversation.
- The Capitan of the aircraft as the pilot in command had not sufficient force and efficient management in the cockpit. (lack of Cockpit Resource Management).
- There were unauthorized actions of flight engineer for shifting engine reversers as well as lack of mutual oversight by crew members in checklist accomplishment during approach and landing.
- The crew has had disagreement about “Go around” due to unsuitable landing situations.
- Presence of General Director of airline in the cockpit had adverse psychological effect on crew efficiency behaviors.
- The DETA airline did not use correct procedure to extend engines No; 1-2-4 life time from Ukrainian company (Aerotechservice co.) and the technical manager of ARIA airline did not control and
supervise the matter accordingly.

Main Cause :
Considering those items in factual information and analysis, the main cause of this accident is “weak Cockpit management between the crew” to use correct landing techniques same as releasing Engine trust reversers – Engine shut down in unsuitable time - ….

Contributive Factors :
Some of contributive factors for this accident occurrence are noted as:
- The copilot and the flight engineer had self activity& decision without the (PIC) coordination.
- The cockpit crew was careless and not paying proper attention toward EGPWS warning.
- Psychological adverse effect on cockpit crew because of presence of General Director of Aria airline

Violation & other deficiencies:
The accident investigation team encountered some violations and deficiencies with ICAO Standards and Iran Local Authority regulation (CAO) which are descript as:
- Poor and in-sufficient supervision controlled of operation &technical manger of Aria Airline.
- The DETA airline has not used proper procedure to receive life time extension of engine and has not passed necessary information to Iranian and Kazakhstan Authorities.
- It has not been designed a headset for flight engineer to make more coordination between the crew, by the aircraft design bureau.
- The crew was not familiar with Iranian AIP completely.
- The total on board persons was not according to written load sheet.
Final Report:

Crash of a Tupolev TU-154M near Qazvin: 168 killed

Date & Time: Jul 15, 2009 at 1133 LT
Type of aircraft:
Operator:
Registration:
EP-CPG
Flight Phase:
Survivors:
No
Schedule:
Tehran - Yerevan
MSN:
87A-748
YOM:
1987
Flight number:
RV7908
Location:
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
168
Aircraft flight hours:
26593
Aircraft flight cycles:
16248
Circumstances:
The three engine aircraft departed Tehran-Imam Khomeiny Airport at 1117LT on a regular schedule flight to Yerevan, carrying 158 passengers and 10 crew members. Sixteen minutes after takeoff, while cruising over Qazvin at FL340, the aircraft suddenly changed its heading to 270° and then entered a rapid descent, losing 20,000 feet in 90 seconds. In a near vertical attitude, the aircraft crashed in an open field, causing a large crater. The aircraft disintegrated on impact and all 168 occupants were killed.
Probable cause:
Failure of the first stage of the high compressor disk on the left engine while the aircraft was flying at FL340, due to fatigue cracks. Debris punctured the engine nacelle, and several hydraulic and fuel lines were cut while all control systems were unserviceable. A huge fire spread on the left side of the airplane and the airplane entered an uncontrolled descent until impact.
Final Report:

Crash of a Britten Norman BN-2A Trislander III-1 on Great Barrier Island

Date & Time: Jul 5, 2009 at 1305 LT
Type of aircraft:
Operator:
Registration:
ZK-LOU
Flight Phase:
Survivors:
Yes
Schedule:
Great Barrier Island - Auckland
MSN:
322
YOM:
1972
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
868
Captain / Total hours on type:
28.00
Circumstances:
At about 1300 on Sunday 5 July 2009, ZK-LOU, a 3-engined Britten Norman BN2A Mk III Trislander operated by Great Barrier Airlines (the company), took off from Great Barrier Aerodrome at Claris on Great Barrier Island on a regular service to Auckland International Airport. On board were 10 passengers and a pilot, all of whom were wearing their seat belts. That morning the pilot had flown a different Trislander from Auckland International Airport to Claris and swapped it for ZK-LOU for the return flight because it was needed for pilot training back in Auckland. Another company pilot had that morning flown ZK-LOU to Claris from North Shore Aerodrome. He had completed a full engine run-up for the first departure of the day, as was usual, and said he noticed nothing unusual with the aeroplane during the approximate 30-minute flight. For the return flight the pilot said he completed the normal after-start checks in ZK-LOU and noticed nothing abnormal. He did not do another full engine run-up because it was not required. He taxied the aeroplane to the start of sealed runway 28, applied full power while holding the aeroplane on brakes and rechecked that the engine gauges were indicating normally before starting the take-off roll. The aeroplane took off without incident, but the pilot said when it was climbing through about 500 feet he heard an unusual “pattering” sound. He also heard the propellers going out of synchronisation, so he attempted to resynchronise them with the propeller controls. He checked the engine’s gauges and noticed that the right engine manifold pressure and engine rotation speed had dropped, so he adjusted the engine and propeller controls to increase engine power. At that time there was a loud bang and he heard a passenger scream. Looking back to his right the pilot saw that the entire propeller assembly for the right engine was missing and that there was a lot of oil spray around the engine cowling. The pilot turned the aeroplane left and completed the engine failure and shutdown checks. He transmitted a distress call on the local area frequency and asked the other company pilot, who was airborne behind him, to alert the local company office that he was returning to Claris. The company office manager and other company pilot noticed nothing unusual with ZK-LOU as it taxied and took off. The other pilot was not concerned until he saw what looked like white smoke and debris emanate from the aeroplane as though it had struck a flock of birds. Despite the failure, ZK-LOU continued to climb, so the pilot said he levelled at about 800 feet and reduced power on the 2 serviceable engines, completed a left turn and crossed over the aerodrome and positioned right downwind for runway 28. There was quite a strong headwind for the landing, so the pilot elected to do a flapless landing and keep the power and speed up a little because of the possibility of some wind shear. The pilot and other personnel said that the cloud was scattered at about 2500 feet, that there were a few showers in the area and that the wind was about 15 to 20 knots along runway 28. The visibility was reported as good. After landing, the pilot stopped the aeroplane on the runway and checked on the passengers before taxiing to the apron. At the apron he shut down the other engines and helped the passengers to the terminal, where they were offered drinks. The company chief executive, who lived locally, and a local doctor attended to the passengers. Three of the passengers received some minor abrasions and scrapes from shattered Perspex and broken interior lining when the propeller struck the side of the fuselage.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The engine propeller assembly separated from the right engine of ZK-LOU in flight and struck the fuselage when the crankshaft failed at the flange that connected it to the propeller hub.
- High-cycle fatigue cracking on the flange that had developed during normal operations from undetected corrosion had reached a critical stage and allowed the flange to fail in overload.
- The crankshaft had inadvertently passed its overhaul service life by around 11% when the failure occurred, but the company had not realized this because of an anomaly in the recorded overseas service hours prior to importation of the engine to New Zealand. Ordinarily, the crankshaft would have been retired before a failure was likely.
- The crankshaft was an older design that has since been progressively superseded by those with flanges less prone to cracking.
- There was no requirement for a specific periodic crack check of the older-design crankshaft flanges, but this has been addressed by the CAA issuing a Continuing Airworthiness Notice on the issue.
- The CAA audit of the company had examined whether its engine overhaul periods were correct, but the audit could not have been expected to discover the anomaly in the overseas-recorded engine hours.
- This failure highlighted the need by potential purchasers of overseas components to follow the guidelines outlined in CAA Advisory Circular 00-1 to scrutinize overseas component records to ensure that the reported in-service hours are accurate.
Final Report:

Crash of an Airbus A310-324 off Moroni: 152 killed

Date & Time: Jun 30, 2009 at 0154 LT
Type of aircraft:
Operator:
Registration:
7O-ADJ
Survivors:
Yes
Schedule:
Sanaa - Moroni
MSN:
535
YOM:
1990
Flight number:
IY626
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
142
Pax fatalities:
Other fatalities:
Total fatalities:
152
Captain / Total flying hours:
7936
Captain / Total hours on type:
5314.00
Copilot / Total flying hours:
3641
Copilot / Total hours on type:
3076
Aircraft flight hours:
53587
Aircraft flight cycles:
18129
Circumstances:
Following an uneventful flight from Sana'a, the crew started a night approach to Moroni-Prince Saïd Ibrahim Airport runway 02. Weather conditions were considered as good with a 10 km visibility, an OAT of 24° C. and a wind from 180° gusting to 25 knots for runway 20. For unknown reasons, the crew initiated a go-around procedure when the aircraft entered an uncontrolled descent and crashed in the sea about 6 km from the airport. A young girl aged 12 was found alive few hours later while 152 other occupants were killed. Both CVR and DFDR were found almost two months later at a depth of 1,200 metres. The final report was published in June 2013.
Probable cause:
The accident was caused by inappropriate actions on part of the crew on flight controls which brought the aircraft into a stall that could not be recovered. These actions were successive to an unstabilized visual approach during which several alarms related to the proximity of the ground, the aircraft configuration and approach to stall sounded. Crew's attention was focused on the management of the path of the aircraft and the location of the runway, and they probably did not have enough mental resources available in this stressful situation, to respond adequately to these different alarms.
Contributing to the accident were the following factors:
- Weather conditions at the airport with winds gusting to 30 knots,
- Lack of training or pre-flight briefing of the crew in accordance with the Yemenia company operations manual, given the reluctance of the pilot to execute the MVI [Visual Maneuvering with Prescribed track] (none of the documents submitted in the investigation shows this training),
- The non-execution of the MVI maneuver by the crew (the plane left the LOC axis after the published point which is 5.2 NM), implying that the crew delayed the turn to reach the right hand downwind leg.
- The non-application by the crew of the procedure following the PULL UP-alarm.
Final Report:

Crash of a Xian MA60 in Caticlan

Date & Time: Jun 25, 2009 at 0755 LT
Type of aircraft:
Operator:
Registration:
RP-C8892
Survivors:
Yes
Schedule:
Manila - Caticlan
MSN:
07 03
YOM:
2008
Flight number:
EZD863
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
55
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Manila, the crew started the descent to Caticlan Airport and was informed that runway 06 was in use due to the wind component. For unknown reasons, the captain decided to land on runway 24. The approach was too long and the aircraft landed too far down the runway, about 950 metres past the runway threshold. Unable to stop within the remaining distance, it overran and came to rest in a grassy area against the perimeter fence. All 59 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Fokker F28 Fellowship 4000 in Sittwe

Date & Time: Jun 6, 2009 at 0820 LT
Type of aircraft:
Operator:
Registration:
XY-ADW
Survivors:
Yes
Schedule:
Yangon - Sittwe
MSN:
11114
YOM:
1977
Flight number:
UB409
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
62
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Yangon, the crew completed the approach to Sittwe Airport in poor weather conditions. The aircraft landed hard on runway 11, causing the right main gear to collapse. The right wing struck the ground and was partially sheared off. The aircraft went out of control, veered off runway to the left and came to rest against a fence. Three occupants, among them the captain, were slightly injured and the aircraft was damaged beyond repair. At the time of the accident, the runway threshold and edge lights as well as the VASIS were unserviceable.

Crash of an Airbus A330-203 off Fernando de Noronha: 228 killed

Date & Time: Jun 1, 2009 at 0014 LT
Type of aircraft:
Operator:
Registration:
F-GZCP
Flight Phase:
Survivors:
No
Schedule:
Rio de Janeiro – Paris
MSN:
660
YOM:
2005
Flight number:
AF447
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
216
Pax fatalities:
Other fatalities:
Total fatalities:
228
Captain / Total flying hours:
6547
Captain / Total hours on type:
4479.00
Copilot / Total flying hours:
2936
Copilot / Total hours on type:
807
Aircraft flight hours:
18870
Aircraft flight cycles:
2644
Circumstances:
On Sunday 31 May 2009, the Airbus A330-203 registered F-GZCP operated by Air France was programmed to perform scheduled flight AF 447 between Rio de Janeiro-Galeão and Paris Charles de Gaulle. Twelve crew members (3 flight crew, 9 cabin crew) and 216 passengers were on board. The departure was planned for 22 h 00. At around 22 h 10, the crew was cleared to start up engines and leave the stand. Takeoff took place at 22 h 29. The Captain was Pilot Not Flying (PNF); one of the copilots was Pilot Flying (PF). At the start of the Cockpit Voice Recorder (CVR) recording, shortly after midnight, the aeroplane was in cruise at flight level 350. Autopilot 2 and auto-thrust were engaged. Auto fuel transfer in the “trim tank” was carried out during the climb. The flight was calm. At 1 h 35, the aeroplane arrived at INTOL point and the crew left the Recife frequency to change to HF communication with the Atlántico Oceanic control centre. A SELCAL test was successfully carried out, but attempts to establish an ADS-C connection with DAKAR Oceanic failed. Shortly afterwards, the co-pilot modified the scale on his Navigation Display (ND) from 320 NM to 160 NM and noted “…a thing straight ahead”. The Captain confirmed and the crew again discussed the fact that the high temperature meant that they could not climb to flight level 370. At 1 h 45, the aeroplane entered a slightly turbulent zone, just before SALPU point. Note: At about 0 h 30 the crew had received information from the OCC about the presence of a convective zone linked to the inter-tropical convergence zone (ITCZ) between SALPU and TASIL. The crew dimmed the lighting in the cockpit and switched on the lights “to see”. The co-pilot noted that they were “entering the cloud layer” and that it would have been good to be able to climb. A few minutes later, the turbulence increased slightly in strength. Shortly after 1 h 52, the turbulence stopped. The co-pilot again drew the Captain’s attention to the REC MAX value, which had then reached flight level (FL) 375. A short time later, the Captain woke the second co-pilot and said “[…] he’s going to take my place”. At around 2 h 00, after leaving his seat, the Captain attended the briefing between the two co-pilots, during which the PF (seated on the right) said specifically that “well the little bit of turbulence that you just saw we should find the same ahead we’re in the cloud layer unfortunately we can’t climb much for the moment because the temperature is falling more slowly than forecast” and that “the logon with DAKAR failed”. Then the Captain left the cockpit. The aeroplane approached the ORARO point. It was flying at flight level 350 and at Mach 0.82. The pitch attitude was about 2.5 degrees. The weight and balance of the aeroplane were around 205 tonnes and 29%. The two copilots again discussed the temperature and the REC MAX. The turbulence increased slightly. At 2 h 06, the PF called the cabin crew, telling them that “in two minutes we ought to be in an area where it will start moving about a bit more than now you’ll have to watch out there” and he added “I’ll call you when we’re out of it”. At around 2 h 08, the PNF proposed “go to the left a bit […]”. The HDG mode was activated and the selected heading decreased by about 12 degrees in relation to the route. The PNF changed the gain adjustment on his weather radar to maximum, after noticing that it was in calibrated mode. The crew decided to reduce the speed to about Mach 0.8 and engine de-icing was turned on. At 2 h 10 min 05, the autopilot then the auto-thrust disconnected and the PF said “I have the controls”. The aeroplane began to roll to the right and the PF made a nose-up and left input. The stall warning triggered briefly twice in a row. The recorded parameters showed a sharp fall from about 275 kt to 60 kt in the speed displayed on the left primary flight display (PFD), then a few moments later in the speed displayed on the integrated standby instrument system (ISIS). The flight control law reconfigured from normal to alternate. The Flight Directors (FD) were not disconnected by the crew, but the crossbars disappeared. Note: Only the speeds displayed on the left side and on the ISIS are recorded on the FDR; the speed displayed on the right side is not recorded. At 2 h 10 min 16, the PNF said “we’ve lost the speeds ” then “alternate law protections”. The PF made rapid and high amplitude roll control inputs, more or less from stop to stop. He also made a nose-up input that increased the aeroplane’s pitch attitude up to 11° in ten seconds. Between 2 h 10 min 18 and 2 h 10 min 25, the PNF read out the ECAM messages in a disorganized manner. He mentioned the loss of autothrust and the reconfiguration to alternate law. The thrust lock function was deactivated. The PNF called out and turned on the wing anti-icing. The PNF said that the aeroplane was climbing and asked the PF several times to descend. The latter then made several nose-down inputs that resulted in a reduction in the pitch attitude and the vertical speed. The aeroplane was then at about 37,000 ft and continued to climb. At about 2 h 10 min 36, the speed displayed on the left side became valid again and was then 223 kt; the ISIS speed was still erroneous. The aeroplane had lost about 50 kt since the autopilot disconnection and the beginning of the climb. The speed displayed on the left side was incorrect for 29 seconds. At 2 h 10 min 47, the thrust controls were pulled back slightly to 2/3 of the IDLE/CLB notch (85% of N1). Two seconds later, the pitch attitude came back to a little above 6°, the roll was controlled and the angle of attack was slightly less than 5°. The aeroplane’s pitch attitude increased progressively beyond 10 degrees and the plane started to climb. From 2 h 10 min 50, the PNF called the Captain several times. At 2 h 10 min 51, the stall warning triggered again, in a continuous manner. The thrust levers were positioned in the TO/GA detent and the PF made nose-up inputs. The recorded angle of attack, of around 6 degrees at the triggering of the stall warning, continued to increase. The trimmable horizontal stabilizer (THS) began a nose-up movement and moved from 3 to 13 degrees pitch-up in about 1 minute and remained in the latter position until the end of the flight. Around fifteen seconds later, the ADR3 being selected on the right side PFD, the speed on the PF side became valid again at the same time as that displayed on the ISIS. It was then at 185kt and the three displayed airspeeds were consistent. The PF continued to make nose-up inputs. The aeroplane’s altitude reached its maximum of about 38,000 ft; its pitch attitude and angle of attack were 16 degrees. At 2 h 11 min 37, the PNF said “controls to the left”, took over priority without any callout and continued to handle the aeroplane. The PF almost immediately took back priority without any callout and continued piloting. At around 2 h 11 min 42, the Captain re-entered the cockpit. During the following seconds, all of the recorded speeds became invalid and the stall warning stopped, after having sounded continuously for 54 seconds. The altitude was then about 35,000 ft, the angle of attack exceeded 40 degrees and the vertical speed was about -10,000 ft/min. The aeroplane’s pitch attitude did not exceed 15 degrees and the engines’ N1’s were close to 100%. The aeroplane was subject to roll oscillations to the right that sometimes reached 40 degrees. The PF made an input on the side-stick to the left stop and nose-up, which lasted about 30 seconds. At 2 h 12 min 02, the PF said, “I have no more displays”, and the PNF “we have no valid indications”. At that moment, the thrust levers were in the IDLE detent and the engines’ N1’s were at 55%. Around fifteen seconds later, the PF made pitch-down inputs. In the following moments, the angle of attack decreased, the speeds became valid again and the stall warning triggered again. At 2 h 13 min 32, the PF said, “[we’re going to arrive] at level one hundred”. About fifteen seconds later, simultaneous inputs by both pilots on the side-sticks were recorded and the PF said, “go ahead you have the controls”. The angle of attack, when it was valid, always remained above 35 degrees. From 2 h 14 min 17, the Ground Proximity Warning System (GPWS) “sink rate” and then “pull up” warnings sounded. The recordings stopped at 2 h 14 min 28. The last recorded values were a vertical speed of -10,912 ft/min, a ground speed of 107 kt, pitch attitude of 16.2 degrees nose-up, roll angle of 5.3 degrees left and a magnetic heading of 270 degrees. No emergency message was transmitted by the crew. The wreckage was found at a depth of 3,900 metres on 2 April 2011 at about 6.5 NM on the radial 019 from the last position transmitted by the aeroplane. Both CVR and DFDR were found 23 months after the accident, in May 2011 at a depth of 3,900 metres. The final report was published in July 2012.
Probable cause:
The obstruction of the Pitot probes by ice crystals during cruise was a phenomenon that was known but misunderstood by the aviation community at the time of the accident. From an operational perspective, the total loss of airspeed information that resulted from this was a failure that was classified in the safety model. After initial reactions that depend upon basic airmanship, it was expected that it would be rapidly diagnosed by pilots and managed where necessary by precautionary measures on the pitch attitude and the thrust, as indicated in the associated procedure. The occurrence of the failure in the context of flight in cruise completely surprised the pilots of flight AF 447. The apparent difficulties with aeroplane handling at high altitude in turbulence led to excessive handling inputs in roll and a sharp nose-up input by the PF. The destabilization that resulted from the climbing flight path and the evolution in the pitch attitude and vertical speed was added to the erroneous airspeed indications and ECAM messages, which did not help with the diagnosis. The crew, progressively becoming de-structured, likely never understood that it was faced with a 'simple' loss of three sources of airspeed information. In the minute that followed the autopilot disconnection, the failure of the attempts to understand the situation and the de-structuring of crew cooperation fed on each other until the total loss of cognitive control of the situation. The underlying behavioral hypotheses in classifying the loss of airspeed information as 'major' were not validated in the context of this accident. Confirmation of this classification thus supposes additional work on operational feedback that would enable improvements, where required, in crew training, the ergonomics of information supplied to them and the design of procedures. The aeroplane went into a sustained stall, signaled by the stall warning and strong buffet. Despite these persistent symptoms, the crew never understood that they were stalling and consequently never applied a recovery manoeuvre. The combination of the ergonomics of the warning design, the conditions in which airline pilots are trained and exposed to stalls during their professional training and the process of recurrent training does not generate the expected behavior in any acceptable reliable way. In its current form, recognizing the stall warning, even associated with buffet, supposes that the crew accords a minimum level of 'legitimacy' to it. This then supposes sufficient previous experience of stalls, a minimum of cognitive availability and understanding of the situation, knowledge of the aeroplane (and its protection modes) and its flight physics. An examination of the current training for airline pilots does not, in general, provide convincing indications of the building and maintenance of the associated skills. More generally, the double failure of the planned procedural responses shows the limits of the current safety model. When crew action is expected, it is always supposed that they will be capable of initial control of the flight path and of a rapid diagnosis that will allow them to identify the correct entry in the dictionary of procedures. A crew can be faced with an unexpected situation leading to a momentary but profound loss of comprehension. If, in this case, the supposed capacity for initial mastery and then diagnosis is lost, the safety model is then in 'common failure mode'. During this event, the initial inability to master the flight path also made it impossible to understand the situation and to access the planned solution.
Thus, the accident resulted from the following succession of events:
- Temporary inconsistency between the airspeed measurements, likely following the obstruction of the Pitot probes by ice crystals that, in particular, caused the autopilot disconnection and the reconfiguration to alternate law;
- Inappropriate control inputs that destabilized the flight path;
- The lack of any link by the crew between the loss of indicated speeds called out and the appropriate procedure;
- The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;
- The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;
- The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it.
These events can be explained by a combination of the following factors:
- The feedback mechanisms on the part of all those involved that made it impossible:
* To identify the repeated non-application of the loss of airspeed information procedure and to remedy this,
* To ensure that the risk model for crews in cruise included icing of the Pitot probes and its consequences;
- The absence of any training, at high altitude, in manual aeroplane handling and in the procedure for 'Vol avec IAS douteuse';
- Task-sharing that was weakened by:
* Incomprehension of the situation when the autopilot disconnection occurred,
* Poor management of the startle effect that generated a highly charged emotional factor for the two copilots;
- The lack of a clear display in the cockpit of the airspeed inconsistencies identified by the computers;
- The crew not taking into account the stall warning, which could have been due to:
* A failure to identify the aural warning, due to low exposure time in training to stall phenomena, stall warnings and buffet,
* The appearance at the beginning of the event of transient warnings that could be considered as spurious,
* The absence of any visual information to confirm the approach-to-stall after the loss of the limit speeds,
* The possible confusion with an overspeed situation in which buffet is also considered as a symptom,
* Flight Director indications that may led the crew to believe that their actions were appropriate, even though they were not,
* The difficulty in recognizing and understanding the implications of a reconfiguration in alternate law with no angle of attack protection.
Final Report:

Crash of a Boeing 737-2K9 in Guadalajara

Date & Time: Apr 27, 2009 at 1800 LT
Type of aircraft:
Operator:
Registration:
XA-MAF
Survivors:
Yes
Schedule:
Cancún – Guadalajara
MSN:
22505/815
YOM:
1981
Flight number:
GMT585
Country:
Crew on board:
8
Crew fatalities:
Pax on board:
108
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Guadalajara-Miguel Hidalgo y Costilla Airport, the pilots encountered technical problems with the landing gear and elected to perform a low pass in front of the tower. ATC confirmed that the landing gear were not fully deployed and locked. The captain decided to perform a wheels up landing. After touchdown on runway 28, the aircraft slid for few dozen metres before coming to rest. The left engine was destroyed by fire and the aircraft was damaged beyond repair. All 116 occupants escaped uninjured.

Crash of a McDonnell Douglas MD-90-30 in Jakarta

Date & Time: Mar 9, 2009 at 1535 LT
Type of aircraft:
Operator:
Registration:
PK-LIL
Survivors:
Yes
Schedule:
Ujung Pandang - Jakarta
MSN:
53573/2182
YOM:
1997
Flight number:
LNI793
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
166
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
800
Aircraft flight hours:
18695
Aircraft flight cycles:
14507
Circumstances:
Lion Mentari Airline (Lion Air) as flight number LNI-793, departed from Sultan Hasanuddin Airport (WAAA), Makassar, Ujung Pandang, Sulawesi at 0636 UTC for Soekarno-Hatta International Airport (WIII), Jakarta. The estimated flight hour from Makassar to Jakarta was 2 hours. The crew consisted of two pilots and four flight attendants. There were 166 adult passengers. The copilot was the pilot flying for the sector, and the pilot in command (PIC) was the support/monitoring pilot. During the approach to runway 25L at Jakarta, the weather at the airport was reported as wind direction 200 degrees, wind speed 20 knots, visibility 1,000 meters, and rain. The PIC reported that he decided to take over control from the copilot. The PIC later reported that he had the runway in sight passing through 1,000 feet on descent, and he disengaged the autopilot at 400 feet. At about 50 feet the aircraft drifted to the right and the PIC initiated corrective action to regain the centreline. The aircraft touched down to the left of the runway 25L centerline and then commenced to drift to the right. The PIC reported that he immediately commenced corrective action by using thrust reverser, but the aircraft increasingly crabbed along the runway with the tail to the right of runway heading. The investigation subsequently found that the right thrust reverser was deployed, but left thrust reverser was not deployed. The aircraft stopped at 0835 on the right side of the runway 25L, 1,095 meters from the departure end of the runway on a heading of 152 degrees; 90 degrees to the runway 25L track. The main landing gear wheels collapsed, and still attached to the aircraft, were on the shoulder of the runway and the nose wheel was on the runway. The passengers and crew disembarked via the front right escape slide and right emergency exit windows. None of the occupants were injured
Probable cause:
The aircraft was not stabilized approach at 100 feet above the runway.
Final Report:

Crash of a Boeing 737-8F2 in Amsterdam: 9 killed

Date & Time: Feb 25, 2009 at 1026 LT
Type of aircraft:
Operator:
Registration:
TC-JGE
Survivors:
Yes
Schedule:
Istanbul - Amsterdam
MSN:
29789/1065
YOM:
2002
Flight number:
TK1951
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
128
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
17000
Captain / Total hours on type:
10885.00
Copilot / Total flying hours:
4146
Copilot / Total hours on type:
44
Circumstances:
Turkish Airlines Flight 1951, a Boeing 737-800, departed Istanbul-Atatürk International Airport (IST) for a flight to Amsterdam-Schiphol International Airport (AMS), The Netherlands. The flight crew consisted of three pilots: a line training captain who occupied the left seat, a first officer under line training in the right seat and an additional first officer who occupied the flight deck jump seat. The first officer under line training was the pilot flying. The en route part of the flight was uneventful. The flight was descending for Schiphol and passed overhead Flevoland at about 8500 ft. At that time the aural landing gear warning sounded. The aircraft continued and was then directed by Air Traffic Control towards runway 18R for an ILS approach and landing. The standard procedure for runway 18R prescribes that the aircraft is lined up at least 8 NM from the runway threshold at an altitude of 2000 feet. The glidepath is then approached and intercepted from below. Lining up at a distance between 5 and 8 NM is allowed when permitted by ATC. Flight 1951 was vectored for a line up at approximately 6 NM at an altitude of 2000 feet. The glide slope was now approached from above. The crew performed the approach with one of the two autopilot and autothrottle engaged. The landing gear was selected down and flaps 15 were set. While descending through 1950 feet, the radio altimeter value suddenly changed to -8 feet. And again the aural landing gear warning sounded. This could be seen on the captain’s (left-hand) primary flight display. The first officer’s (right-hand) primary flight display, by contrast, indicated the correct height, as provided by the right-hand system. The left hand radio altimeter system, however, categorised the erroneous altitude reading as a correct one, and did not record any error. In turn, this meant that it was the erroneous altitude reading that was used by various aircraft systems, including the autothrottle. The crew were unaware of this, and could not have known about it. The manuals for use during the flight did not contain any procedures for errors in the radio altimeter system. In addition, the training that the pilots had undergone did not include any detailed system information that would have allowed them to understand the significance of the problem. When the aircraft started to follow the glidepath because of the incorrect altitude reading, the autothrottle moved into the ‘retard flare’ mode. This mode is normally only activated in the final phase of the landing, below 27 feet. This was possible because the other preconditions had also been met, including flaps at (minimum) position 15. The thrust from both engines was accordingly reduced to a minimum value (approach idle). This mode was shown on the primary flight displays as ‘RETARD’. However, the right-hand autopilot, which was activated, was receiving the correct altitude from the right-hand radio altimeter system. Thus the autopilot attempted to keep the aircraft flying on the glide path for as long as possible. This meant that the aircraft’s nose continued to rise, creating an increasing angle of attack of the wings. This was necessary in order to maintain the same lift as the airspeed reduced. In the first instance, the pilots’ only indication that the autothrottle would no longer maintain the pre-selected speed of 144 knots was the RETARD display. When the speed fell below this value at a height of 750 feet, they would have been able to see this on the airspeed indicator on the primary flight displays. When subsequently, the airspeed reached 126 knots, the frame of the airspeed indicator also changed colour and started to flash. The artificial horizon also showed that the nose attitude of the aircraft was becoming far too high. The cockpit crew did not respond to these indications and warnings. The reduction in speed and excessively high pitch attitude of the aircraft were not recognised until the approach to stall warning (stick shaker) went off at an altitude of 460 feet. The first officer responded immediately to the stick shaker by pushing the control column forward and also pushing the throttle levers forward. The captain however, also responded to the stick shaker commencing by taking over control. Assumingly the result of this was that the first officer’s selection of thrust was interrupted. The result of this was that the autothrottle, which was not yet switched off, immediately pulled the throttle levers back again to the position where the engines were not providing any significant thrust. Once the captain had taken over control, the autothrottle was disconnected, but no thrust was selected at that point. Nine seconds after the commencement of the first approach to stall warning, the throttle levers were pushed fully forward, but at that point the aircraft had already stalled and the height remaining, of about 350 feet, was insufficient for a recovery. According to the last recorded data of the digital flight data recorder the aircraft was in a 22° ANU and 10° Left Wing Down (LWD) position at the moment of impact. The airplane impacted farmland. The horizontal stabilizer and both main landing gear legs were separated from the aircraft and located near the initial impact point. The left and right engines had detached from the aircraft. The aft fuselage, with vertical stabilizer, was broken circumferentially forward of the aft passenger doors and had sustained significant damage. The fuselage had ruptured at the right side forward of the wings. The forward fuselage section, which contained the cockpit and seat rows 1 to 7, had been significantly disrupted. The rear fuselage section was broken circumferentially around row 28.
Probable cause:
During the accident flight, while executing the approach by means of the instrument landing system with the right autopilot engaged, the left radio altimeter system showed an incorrect height of -8 feet on the left primary flight display. This incorrect value of -8 feet resulted in activation of the ‘retard flare’ mode of the auto-throttle, whereby the thrust of both engines was reduced to a minimal value (approach idle) in preparation for the last phase of the landing. Due to the approach heading and altitude provided to the crew by air traffic control, the localiser signal was intercepted at 5.5 NM from the runway threshold with the result that the glide slope had to be intercepted from above. This obscured the fact that the auto-throttle had entered the retard flare mode. In addition, it increased the crew’s workload. When the aircraft passed 1000 feet height, the approach was not stabilized so the crew should have initiated a go around. The right autopilot (using data from the right radio altimeter) followed the glide slope signal. As the airspeed continued to drop, the aircraft’s pitch attitude kept increasing. The crew failed to recognize the airspeed decay and the pitch increase until the moment the stick shaker was activated. Subsequently the approach to stall recovery procedure was not executed properly, causing the aircraft to stall and crash.
Final Report: