Accidents and Incidents
This directory contains articles about particular Accidents and Incidents that are considered illustrative of the contemporary safety issues and recommended potential solutions. The information contained in the article summarising an individual accident or incident is derived from the published official investigation report, which may in each case be found on the SKYbrary bookshelf wherever possible in English as provided by the publishing Investigation Agency. A direct link to each official report is provided at the end of each summary article. The complete list of events is provided on this and the following pages in the order of the ICAO aircraft type designator in alphabetical order.
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Time of Day
Phase of Flight
Air Ground Communication
Controlled Flight Into Terrain
Loss of Control
Loss of Separation
Wake Vortex Turbulence
AW Affected System(s)
AW Contributing Factor(s)
Causal Factor Group(s)
AT76, Surabaya Indonesia, 2014 On 11 June 2014, an ATR 72-600 sustained substantial damage after hitting an object after touchdown at Surabaya but was able to taxi to post-flight parking. The Investigation found that several sizeable items of equipment had been left on the runway after it had been closed for overnight maintenance work and that no runway inspection had been carried out once the work was complete. It was concluded that departing aircraft had probably become airborne before reaching the reported location and that ATC had reacted with insufficient urgency after beginning to receive FOD reports from previous landing aircraft once daylight prevailed.
AT76, vicinity Al Hoceima Morocco, 2018 On 9 July 2018, an ATR 72-600 continued a non-precision approach to Al Hoceima below the procedure MDA without obtaining visual reference and subsequently struck the sea surface twice, both times with a vertical acceleration exceeding structural limits before successfully climbing away and diverting to Nador having reported a bird strike. The Investigation attributed the accident to the Captain’s repeated violation of operating procedures which included another descent below MDA without visual reference the same day and the intentional deactivation of the EGPWS without valid cause. There was significant fuselage structure and landing gear damage but no occupant injuries.
AT76, vicinity Dublin Ireland, 2016 On 2 September 2016, an ATR72-600 cleared to join the ILS for runway 28 at Dublin continued 800 feet below cleared altitude triggering an ATC safe altitude alert which then led to a go around from around 1000 feet when still over 5nm from the landing runway threshold. The Investigation attributed the event broadly to the Captain’s inadequate familiarity with this EFIS-equipped variant of the type after considerable experience on other older analogue-instrumented variants, noting that although the operator had provided simulator differences training, the -600 was not classified by the certification authority as a type variant.
AT76, vicinity Moranbah Queensland Australia, 2013 On 15 May 2013, an ATR 72-600 on a visual approach to Moranbah descended sufficiently low in order to avoid entering cloud that a number of TAWS Warnings were activated. All were a consequence of the descent to below 500 feet agl at a high rate of descent which appeared not to have been appreciated by the flight crew.
AT76, vicinity Taipei Songshan Taiwan, 2015 On 4 February 2015, a TransAsia Airways ATR 72-600 crashed into the Keelung River in central Taipei shortly after taking off from nearby Songshan Airport after the crew mishandled a fault on one engine by shutting down the other in error. They did not realise this until recovery from loss of control due to a stall was no longer possible. The Investigation found that the initial engine fault occurred before getting airborne and should have led to a low-speed rejected take-off. Failure to follow SOPs and deficiencies in those procedures were identified as causal.
ATP, Birmingham UK, 2020 On 22 May 2020, a BAe ATP made a go around after the First Officer mishandled the landing flare at Birmingham and when the Captain took over for a second approach, his own mishandling of the touchdown led to a lateral runway excursion. The Investigation found that although the prevailing surface wind was well within the limiting crosswind component, that component was still beyond both their handling skill levels. It also found that they were both generally inexperienced on type, had not previously encountered more than modest crosswind landings and that their type training in this respect had been inadequate.
ATP, en-route, Oxford UK, 1991 On 11 August 1991, an British Aerospace ATP, during climb to flight level (FL) 160 in icing conditions, experienced a significant degradation of performance due to propeller icing accompanied by severe vibration that rendered the electronic flight instruments partially unreadable. As the aircraft descended below cloud, control was regained and the flight continued uneventfully.
ATP, Helsinki Finland, 2010 On 11 January 2010, a British Aerospace ATP crew attempting to take off from Helsinki after a two-step airframe de/anti icing treatment (Type 2 and Type 4 fluids) were unable to rotate and the take off was successfully rejected from above V1. The Investigation found that thickened de/anti ice fluid residues had frozen in the gap between the leading edge of the elevator and the horizontal stabiliser and that there had been many other similarly-caused occurrences to aircraft without powered flying controls. There was concern that use of such thickened de/anti ice fluids was not directly covered by safety regulation.
ATP, Jersey Channel Islands, 1998 On 9 May 1998, a British Regional Airlines ATP was being pushed back for departure at Jersey in daylight whilst the engines were being started when an excessive engine power setting applied by the flight crew led to the failure of the towbar connection and then to one of the aircraft's carbon fibre propellers striking the tug. A non standard emergency evacuation followed. All aircraft occupants and ground crew were uninjured.
ATP, Vilhelmina Sweden, 2016 On 6 April 2016, a BAe ATP partly left the side of the runway soon after touchdown, regaining it after 155 metres before completing its landing roll. It sustained damage rendering it unfit to continue flying but this was not noticed until five further flights had been made. Investigation attributed the excursion to lack of pilot response to unexpected beta range power and the continued flying to the aircraft Captain's failure to ensure proper event recording, accurate operator notification or a post-excursion engineering inspection of the aircraft. Systemic inadequacy in safety management and culture at the operator was identified.
B190 / B190, Auckland NZ, 2007 On 1 August 2007, the crew of a Beech 1900 aircraft holding on an angled taxiway at Auckland International Airport mistakenly accepted the take-off clearance for another Beech 1900 that was waiting on the runway and which had a somewhat similar call sign. The pilots of both aircraft read back the clearance. The aerodrome controller heard, but did not react to, the crossed transmissions. The holding aircraft entered the runway in front of the cleared aircraft, which had commenced its take-off. The pilots of both aircraft took avoiding action and stopped on the runway without any damage or injury.
B190 / B737, Calgary Canada, 2014 On 29 March 2014, a Beech 1900D being taxied by maintenance personnel at Calgary entered the active runway without clearance in good visibility at night as a Boeing 737-700 was taking off. The 737 passed safely overhead. The Investigation found that the taxiing aircraft had taken a route completely contrary to the accepted clearance and that the engineer on control of the aircraft had not received any relevant training. Although the airport had ASDE in operation, a transponder code was not issued to the taxiing aircraft as required and stop bar crossing detection was not enabled at the time.
B190 / BE9L, Quincy IL USA, 1996 On 19 November 1996, a Beech 1900C which had just landed and a Beech King Air A90 which was taking off collided at the intersection of two runways at the non-Towered Quincy Municipal Airport. Both aircraft were destroyed by impact forces and fire and all occupants of both aircraft were killed. The Investigation found that the King Air pilots had failed to monitor the CTAF or properly scan visually for traffic. The loss of life of the Beech 1900 occupants, who had probably survived the impact, was attributed largely to inability to open the main door of the aircraft.
B190 / Vehicle, Trail BC Canada, 2018 On 12 December 2018, the flight crew of a Beechcraft 1900 landing at the uncontrolled airport at Trail after an into- sun offset visual approach failed to see a runway inspection vehicle coming towards them until after touchdown. Maximum reverse and braking and an increased vehicle speed to exit combined to prevent collision by 4 seconds. The Investigation found that the mandatory airport safety management system was dysfunctional with relevant driver procedures either not followed or nonexistent and noted that two other recent runway incursions had been deemed unrelated to airport operations so that no risk review was carried out.
B190, Blue River BC Canada, 2012 On 17 March 2012, the Captain of a Beech 1900C operating a revenue passenger flight lost control of the aircraft during landing on the 18metre wide runway at destination after an unstabilised day visual approach and the aircraft veered off it into deep snow. The Investigation found that the Operator had not specified any stable approach criteria and was not required to do so. It was also noted that VFR minima had been violated and, noting a fatal accident at the same aerodrome five months previously, concluded that the Operators risk assessment and risk management processes were systemically deficient.
B190, vicinity Bebi south eastern Nigeria, 2008 On 15 March 2008, a Beech 1900D on a non-revenue positioning flight to a private airstrip in mountainous terrain flown by an inadequately-briefed crew without sufficient guidance or previous relevant experience impacted terrain under power whilst trying to locate the destination visually after failing to respond to a series of GPWS Alerts and a final PULL UP Warning. Whilst attributing the accident to the crew, the Investigation also found a range of contributory deficiencies in respect of the Operator, official charting and ATS provision and additional deficiencies in the conduct of the unsuccessful SAR activity after the aircraft became overdue.
B190, vicinity Charlotte NC USA, 2003 On 8 January 2003, a B190, operated by Air Midwest, crashed shortly after take off from Charlotte, NC, USA, following loss of pitch control during takeoff. The accident was attributed to incorrect rigging of the elevator control system compounded by the airplane being outside load and balance limitations.
B190, vicinity Lihue Hawaii, 2008 On 14 January 2008, a single pilot Beech 1900C on a non scheduled mail flight which had departed from Honolulu disappeared during a visual dark night approach at its destination. The Investigation concluded that the pilot had become spatially disoriented and lost control of the aircraft.
B38M, en-route south east of Addis Ababa Ethiopia, 2019 On 10 March 2019, a Boeing 738 MAX 8 left stick shaker activated immediately after takeoff from Addis Ababa for no apparent reason and remained on. A succession of four pitch down manoeuvres not initiated by the crew subsequently occurred and recovery from the final one was not achieved. Terrain impact followed a high speed dive six minutes after takeoff. The Investigation attributed the loss of control to an erroneous single source angle of attack input to the Manoeuvring Characteristics Augmentation System (MCAS) from which, in the absence of an applicable non-normal procedure or appropriate training, recovery was not achievable.
B38M, en-route, northeast of Jakarta Indonesia, 2018 On 29 October 2018, a Lion Air Boeing 737-MAX 8 crew had difficulty controlling the pitch of their aircraft after takeoff from Jakarta and after eventually losing control, a high speed sea impact followed. The Investigation found that similar problems had also affected the aircraft s previous flight following installation of a faulty angle-of-attack sensor and after an incomplete post-flight defect entry, rectification had not occurred. Loss of control occurred because the faulty sensor was the only data feed to an undisclosed automatic pitch down system, MCAS, which had been installed on the 737-MAX variant without recognition of its potential implications.
B38M, Helsinki Finland, 2019 On 18 January 2019, two aircraft taxiing for departure at Helsinki were cleared to cross the landing runway between two landing aircraft. Landing clearance for the second was given once the crossing traffic had cleared as it passed 400 feet in expectation that the previous landing aircraft would also shortly be clear. However, the first landing aircraft was slower than expected clearing the runway and so the second was instructed to go-around but did not then do so because this instruction was lost in the radar height countdown below 50 feet and the runway was seen clear before touchdown.
B462, Cape Town South Africa, 2009 On 19 March 2009 a BAe 146-200 being operated by South African Airlink on a scheduled passenger flight from George to Cape Town in day VMC experienced a flameout of all four engines during the landing roll at Cape Town. The aircraft had enough momentum to roll forward on the runway and vacate onto a taxiway and the APU continued to provide electrical power to the hydraulic system, which facilitated braking and directional control. It was then towed from the taxiway to the apron and the passengers disembarked normally.
B462, Stord Norway, 2006 On 10 October 2006, a BAE Systems 146-200 being operated by Danish airline Atlantic Airways on a passenger flight from Sola to Stord overran the end of runway 33 at destination at a slow speed in normal visibility at dawn (but just prior to the accepted definition of daylight) before plunging down a steep slope sustaining severe damage and catching fire immediately it had come to rest. The rapid spread of the fire and difficulties in evacuation resulted in the death of four of the 16 occupants and serious injury to six others. The aircraft was completely destroyed.
B463 / PA38 Birmingham UK, 1999 On 28 April 1999, a BAe 146-300 departing Birmingham began its daylight take off from Runway 33 without ATC clearance just prior to the touchdown of a PA38 on the intersecting runway 06. Collision was very narrowly avoided after the Controller intervened and the BAe 146 rejected its take off, just missing the PA38 which had stopped just off the runway 33 centreline. The Investigation noted the 146 pilots belief that a take off clearance had been issued but also that no attempt appeared to have been made to read it back or confirm it with the First Officer.
B463, en-route, South of Frankfurt Germany, 2005 On 12 March 2005, the crew of a BAe 146-300 climbing out of Frankfurt lost elevator control authority and an un-commanded descent at up to 4500 fpm in a nose high pitch attitude occurred before descent was arrested and control regained. After landing using elevator trim to control pitch, significant amounts of de/anti-icing fluid residues were found frozen in the elevator/stabilizer and aileron/rudder gaps. The Investigation confirmed that an accumulation of hygroscopic polymer residues from successive applications of thickened de/anti ice fluid had expanded by re-hydration and then expanded further by freezing thus obstructing the flight controls.
B463, Khark Island Iran, 2016 On 19 June 2016, a BAe 146-300 landed long at Khark Island and overran the end of the runway at speed with the aircraft only stopping because the nose landing gear collapsed on encountering uneven ground. The Investigation attributed the accident - which caused enough structural damage for the aircraft to be declared a hull loss - entirely to the decisions and actions of the aircraft commander who failed to go around from an unstabilised approach, landed long and then did not ensure maximum deceleration was achieved. The monitoring role of the low experience First Officer was ineffective.
B703, Sydney Australia, 1969 On 1 December 1969, a Boeing 707-320 being operated by Pan Am and making a daylight take off from Sydney, Australia ran into a flock of gulls just after V1 and prior to rotation and after a compressor stall and observed partial loss of thrust on engine 2 (only), the aircraft commander elected to reject the take off. Despite rapid action to initiate maximum braking and the achievement of full reverse thrust on all engines including No 2, this resulted in an overrun of the end of the runway by 170m and substantial aircraft damage. A full emergency evacuation was carried out with no injuries to any of the occupants. There was no fire.
B712 / CRJ7, vicinity Strasbourg France, 2019 On 12 April 2019, a Boeing 717-200 commenced a go around at Strasbourg because the runway ahead was occupied by a departing Bombardier CRJ700 which subsequently, despite co-ordinated TCAS RAs, then came to within 50 feet vertically when only 740 metres apart laterally as the CRJ, whose crew did not see the 717, passed right to left in front of it. The Investigation attributed the conflict primarily to a series of flawed judgements by the TWR controller involved whilst also noting one absent and one inappropriate ATC procedure which respectively may have provided a context for the resultant risk.
B712, Darwin Australia, 2008 On 7 February 2008, a Boeing 717-200 being operated by Australian airline National Jet on a scheduled passenger service from Nhulunbuy (Gove) to Darwin flew an unstabilised night visual approach at the destination and made a very hard landing. The landing roll was completed and the aircraft taxied to the terminal. None of the 94 occupants were injured but the aircraft was suffered substantial structural damage and damage to the left hand main landing gear.
B712, en-route, Union Star MO USA, 2005 On 12 May 2005, a Boeing 717 crew climbed in night IMC without selecting the appropriate anti-icing systems on and as a result lost control. The non-standard crew response led to an eight minute period of pitch excursions which occurred over a 13,000 feet height band at recorded ground speeds between 290 and 552 knots prior to eventual recovery and included a split in control columns some two minutes into the upset. The Investigation concluded that the aircraft had been fully serviceable with all deviations from normal flight initiated or exacerbated by the control inputs of the flight crew.
B712, en-route, Western Australia, 2006 On 28 February 2006, a Boeing 717-200 being operated by National Jet for Qantas Link on a domestic scheduled passenger flight from Paraburdoo to Perth, Western Australia in day IMC experienced an activation of the stall protection system just after the aircraft had levelled at a cruise altitude of FL340. The response of the flight crew was to initiate an immediate descent without either declaring an emergency or obtaining ATC clearance and, as a result, procedural separation against opposite direction traffic at FL320 was lost. The 72 occupants were uninjured and the aircraft was undamaged.
B712, vicinity Kalgoorlie Western Australia, 2010 On 13 October 2010, a Boeing 717-200 being operated by Cobham Aviation Services Australia for QantasLink on a scheduled passenger flight from Perth to Kalgoorlie Western Australia carried out two consecutive approaches at destination in day VMC which resulted in stick shaker activations and subsequent go arounds. A third approach at a higher indicated airspeed was uneventful and continued to a landing. There were no abrupt manoeuvres and none of the 102 occupants were injured.
B721, Kigali Rwanda, 2020 On 13 November 2020, a Boeing 727-100 configured for cargo operations veered partially off the landing runway at Kigali after a late touchdown on a wet runway before regaining it approximately 1,000 metres later. The Investigation concluded that viscous hydroplaning after touchdown which occurred a significant distance left of the runway centreline had been contributory but absence of a prior go-around was causal. It was also found that the flight crew licences were invalid and that there were significant discrepancies in respect of the aircraft registration, the status of the operator and the validity of the Air Operator Certificate.
B722 / BE10, Atlanta GA USA, 1990 On 18 January 1990, a Boeing 727-200 landing at Atlanta at night and in good visibility in accordance with an unconditional clearance failed to see that a Beechcraft King Air, which had landed ahead of it, had yet to clear the runway. The 727 was unable to avoid a collision after a late sighting. The 727 sustained substantial damage and the King Air was destroyed. The Investigation attributed the collision to a combination of the failure of the runway controller to detect the lack of separation resulting from their issue of multiple landing clearances and the inadequacy of relevant ATC procedures.
B722, Cotonou Benin, 2003 On 25 December 2003, a Boeing 727-200 being operated by UTA (Guinea) on a scheduled passenger flight from Cotonou to Beirut with a planned stopover at Kufra, Libya, failed to get properly airborne in day VMC from the 2400 metre departure runway and hit a small building 2.45 metres high situated on the extended centreline 118 metres beyond the end of the runway. The right main landing gear broke off and ripped off a part of the trailing edge flaps on the right wing. The airplane then banked slightly to the right and crashed onto the beach where it broke into several pieces and ended up in the sea where the depth of water varied between three and ten metres. Of the estimated 163 occupants, 141 were killed and the remainder seriously injured.
B722, Hamilton OT Canada 2008 On 22 July 2008, a Kelowna Flightcraft Air Charter Ltd. Boeing 727-200 was operating a cargo flight from Moncton NB, to Hamilton, OT. After radar vectoring for an approach to Runway 06 at Hamilton, the aircraft touched down hard and bounced before touching down hard a second time. Immediately after the second touchdown, a go-around was initiated. During rotation, the tailskid made contact with the runway. The thrust reverser actuator fairing and the number 2 engine tailpipe made contact with the ground off the departure end of the runway. The aircraft climbed away and then returned for a normal landing on Runway 12. There were no injuries; the aircraft sustained only minor damage.
B722, Lagos Nigeria, 2006 On 7 September 2006, a DHL Boeing 727-200 overran the runway at Lagos by 400 metres after the First Officer was permitted to attempt a landing in challenging weather conditions on a wet runway off an unstable ILS approach. Following a long and fast touchdown at maximum landing weight, a go around was then called after prior selection of thrust reversers but was not actioned and a 400 metre overrun onto soft wet ground followed. The accident was attributed to poor tactical decision making by the aircraft commander.
B722, Moncton Canada, 2010 On 24 March 2010, a Boeing 727-200 being operated by Canadian company Cargojet AW on a scheduled cargo flight from Hamilton Ontario to Moncton New Brunswick failed to stop after a night landing on 1875 metre long runway 06 at destination in normal ground visibility and eventually stopped in deep mud approximately 100 metres beyond the runway end and approximately 40 metres past the end of the paved runway end strip. The three operating flight crew, who were the only occupants, were uninjured and the aircraft received only minor damage.
B732 / A321, Manchester UK, 2004 On 29 February 2004, a Boeing 737-200 crossed an active runway in normal daylight visibility ahead of a departing Airbus A321, the crew of which made a high speed rejected take off upon sighting the other aircraft after hearing its crossing clearance being confirmed. Both aircraft were found to have been operating in accordance with their acknowledged ATC clearances issued by the same controller. An alert was generated by the TWR conflict detection system but it was only visually annunciated and had not been noticed. Related ATC procedures were subsequently reviewed and improved.
B732, en-route, Maui Hawaii, 1988 On 28 April 1988, a Boeing 737-200, operated by Aloha Airlines experienced an explosive depressurisation and structural failure at FL 240. Approximately 5.5 metres (or 18 feet) of cabin covering and structure was detached from the aircraft during flight. As result of the depressurisation, a member of the cabin crew was fatally injured. The flight crew performed an emergency descent, landing at Kahului Airport on the Island of Maui, Hawaii.
B732, London Gatwick UK, 1993 On 20 October 1993, a Boeing 737-200 being operated by Air Malta on a scheduled passenger flight from Malta to London Gatwick landed at destination on the taxiway parallel to the runway for which landing clearance had been given in good visibility at night after a Surveillance Radar Approach (SRA) terminating at 2 miles from touchdown had been conducted in VMC. There was no damage to the aircraft or injury to the occupants and the aircraft taxied to the allocated gate after the landing.
B732, Manchester UK, 1985 On 22nd August 1985, a B737-200 being operated by British Airtours, a wholly-owned subsidiary of British Airways, suffered an uncontained engine failure, with consequent damage from ejected debris enabling the initiation of a fuel-fed fire which spread to the fuselage during the rejected take off and continued to be fuel-fed after the aircraft stopped, leading to rapid destruction of the aircraft before many of the occupants had evacuated.
B732, Medan Indonesia, 2005 On 5 September 2005, a Boeing 737-200 being operated by Mandala Airlines on a scheduled domestic passenger flight from Medan, Indonesia to Jakarta failed to become properly airborne during the attempted take off from from runway 23 in day VMC and, after failing to remain airborne, overran the end of the runway at speed finally coming to a stop outside the airport perimeter. The aircraft was destroyed by impact forces and a subsequent fire and 100 of the 117 occupants were killed and 15 seriously injured. The aircraft collided with residential property, vehicles and various other obstructions and as a result a further 49 people on the ground were killed and a further 26 seriously injured.
B732, Pekanbaru Indonesia, 2002 On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.
B732, vicinity Abuja Nigeria, 2006 On 29 October 2006, an ADC Airlines Boeing 737-200 encountered wind shear almost immediately taking off from Abuja into adverse weather associated with a very rapidly developing convective storm. Unseen from the apron or ATC TWR it stalled, crashed and burned after just over one minute airborne killing 96 of the 105 occupants. The Investigation concluded that loss of control during the wind shear encounter was not inevitable but was a consequence of inappropriate crew response. Concerns about the quality of crew training and competency validation were also raised.
B732, vicinity Islamabad Pakistan, 2012 On 20 April 2012, the crew of a Boeing 737-200 encountered negative wind shear during an ILS final approach at night in lMC and failed to respond with the appropriate recovery actions. The aircraft impacted the ground approximately 4 nm from the threshold of the intended landing runway. The Investigation attributed the accident to the decision to continue to destination in the presence of adverse convective weather and generally ineffective flight deck management and noted that neither pilot had received training specific to the semi-automated variant of the 200 series 737 being flown and had no comparable prior experience.
B732, vicinity Resolute Bay Canada, 2011 On 20 August 2011, a First Air Boeing 737-200 making an ILS approach to Resolute Bay struck a hill east of the designated landing runway in IMC and was destroyed. An off-track approach was attributed to the aircraft commander s failure to recognise the effects of his inadvertent interference with the AP ILS capture mode and the subsequent loss of shared situational awareness on the flight deck. The approach was also continued when unstabilised and the Investigation concluded that the poor CRM and SOP compliance demonstrated on the accident flight were representative of a wider problem at the operator.
B732, vicinity Tamanrassat Algeria, 2003 On 6 March 2003, a Boeing 737-200 being operated by Air Algerie had just become airborne during a daylight departure when the left hand engine suddenly failed just after the PF had called for gear up . Shortly afterwards, the aircraft commander, who had been PNF for the departure, took control but the normal pitch attitude was not reduced to ensure that a minimum airspeed of V2 was maintained and landing gear was not retracted. The aircraft lost airspeed, stalled and impacted the ground approximately 1nm from the point at which it had become airborne. A severe post crash fire occurred and the aircraft was destroyed and all on board except one passenger, were killed.
B732, vicinity Washington National DC USA, 1982 On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.
B733 / B744, Chicago IL USA, 2006 On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O Hare Airport. The occurrence is attributed to ATC error.
B733 / DH8D, Fort McMurray Canada, 2014 On 4 August 2014, a Boeing 737-300 making a day visual approach at Fort McMurray after receiving an ILS/DME clearance lined up on a recently-constructed parallel taxiway and its crew were only alerted to their error shortly before touchdown by the crew of a DHC8-400 which was taxiing along the same taxiway in the opposite direction. This resulted in a go around being commenced from 46 feet agl. The Investigation noted that both pilots had been looking out during the final stages of the approach and had ignored important SOPs including that for a mandatory go around from an unstable approach.
B733 / SW4, Los Angeles CA USA, 1991 On 1 February 1991, a Boeing 737-300 had just made a normal visibility night touchdown on Los Angeles runway 24L in accordance with its clearance when its crew saw another aircraft stationary ahead of them on the same runway. Avoidance was impossible in the time available and a high speed collision and post-impact fire destroyed both aircraft and killed 34 of their 101 occupants and injured 30 others. The other aircraft was subsequently found to have been a Fairchild Metroliner cleared to line up and wait by the same controller who had then cleared the 737 to land.
B733 / vehicle, Amsterdam Netherlands, 2010 On 18 December 2010, the ATC Runway Controller responsible for runway 24 at Amsterdam gave a daylight take off clearance in normal visibility to a Norwegian Boeing 737-300 whilst a bird control vehicle which they had earlier given clearance to enter the runway was still on it. The departing aircraft overflew the vehicle without noticing it. The subsequent investigation highlighted significant differences between the procedures for active runway access at Amsterdam and corresponding international practice as well as finding that integrated safety investigation and overall safety management at the airport were systemically ineffective.
B733, Amsterdam Netherlands, 2010 On 10 February 2010 a KLM Boeing 737-300 unintentionally made a night take off from Amsterdam in good visibility from the taxiway parallel to the runway for which take off clearance had been given. Because of the available distance and the absence of obstructions, the take off was otherwise uneventful. The Investigation noted the familiarity of the crew with the airport and identified apparent complacency.
B733, Aqaba Jordan, 2017 On 17 September 2017, a Boeing 737-300 requested and was approved for a visual approach to Aqaba which involved a significant tailwind component and, after approaching at excessive speed, it touched down late and overran the 3000 metre runway onto sandy ground. The Investigation found that despite EGPWS Alerts relating to both the high rate of descent and late configuration, the Captain had instructed the First Officer to continue what was clearly an unstabilised approach and when touchdown had still not occurred with around 1000 metres of runway left, the Captain took over but was unable to prevent an overrun.
B733, Birmingham UK, 2009 On 6 February 2009, the crew of a Boeing 737-300 departing Birmingham successfully rejected take off from well above V1 when it became clear to the First Officer as handling pilot, that it was impossible to rotate. The Investigation found that cause of the rotation difficulty was that the crew had failed to set the stabiliser trim to the appropriate position for take off after delaying this action beyond the normal point in pre flight preparations because ground de icing was in progress and not subsequently noticing.
B733, Birmingham UK, 2012 On 21 September 2012, an Aurela Boeing 737-300 lost directional control and left the paved surface when attempting to turn off the landing runway at Birmingham expeditiously to avoid the following aircraft having to go around. The Investigation noted that the range of the approaching aircraft - still 2.5nm as the incident aircraft began to clear the runway - had not been communicated and concluded that the speed of the aircraft had been inappropriate for the prevailing wet surface conditions as well as unnecessary to prevent a go around by the following aircraft.
B733, Burbank CA USA, 2000 On 5 March 2000, a Boeing 737-300 being operated by Southwest Airlines on a scheduled passenger flight from Las Vegas to Burbank overran the landing destination runway in normal day visibility after a steep visual approach had been flown at an abnormally high speed. The aircraft exited the airport perimeter and came to a stop on a city street near a gas station. An emergency evacuation of the 142 occupants led to 2 serious injuries and 42 minor injuries and the aircraft was extensively damaged.
B733, Chambery France, 2012 On 14 April 2012, a Titan Airways Boeing 737-300 attempted to take off from Chambery with incorrect reference speeds taken from the EFB used for performance calculations. As a consequence, the pressure hull was damaged by a tail strike during take off, although not sufficiently to affect cabin pressure during the subsequent flight. The Investigation concluded that the accident raised regulatory issues in respect of the general design and use of EFB computers to calculate performance data.
B733, en-route, north of Antalya Turkey, 2009 On 2 May 2009, a Boeing 737-300 being operated by French airline Europe Airpost on a passenger charter flight from Marseille to Antalya, Turkey was descending in day VMC towards destination when a sudden and severe turbulence encounter led to a temporary loss of control and stall. Recovery was achieved and none of the 115 occupants was injured and the aircraft was undamaged.
B733, en-route, north of Narrandera NSW Australia, 2018 On 15 August 2018, a Boeing 737-300SF crew concerned about a small residual pressure in a bleed air system isolated after a fault occurred en-route then sought and were given non-standard further troubleshooting guidance by company maintenance which, when followed, led directly and indirectly to additional problems including successive incapacitation of both pilots and a MAYDAY diversion. The Investigation found that the aircraft concerned was carrying a number of relevant individually minor undetected defects which meant the initial crew response was not completely effective and prompted a request for in-flight assistance which was unnecessary and led to the further outcomes.
B733, en-route, north of Yuma AZ USA, 2011 On 1 April 2011, a Southwest Boeing 737-300 climbing through FL340 experienced a sudden loss of pressurisation as a section of fuselage crown skin ruptured. A successful emergency descent was made with a diversion to Yuma, where the aircraft landed half an hour later. Investigation found that the cause of the failure was an undetected manufacturing fault in the 15 year-old aircraft. One member of the cabin crew and an off duty staff member who tried to assist him became temporarily unconscious after disregarding training predicated on the time of useful consciousness after sudden depressurisation.
B733, en-route, northwest of Athens Greece, 2005 On 14 August 2005, a Boeing 737-300 was released to service with the cabin pressurisation set to manual. This abnormal setting was not detected by the flight crew involved during standard checks. They took no corrective action after take-off when a cabin high altitude warning occurred. The crew lost consciousness as the aircraft climbed on autopilot and after eventual fuel exhaustion, the aircraft departed controlled flight and impacted terrain. The Investigation found that inadequate crew performance had occurred within a context of systemic organisational safety deficiencies at the Operator compounded by inadequate regulatory oversight.
B733, en-route, Santa Barbara CA USA, 1999 On 2 September 1999, a United Airlines Boeing Boeing 737-300 in the cruise at FL240, experienced severe turbulence due to an encounter with the wake vortex from a preceding MD11 on a similar track which had climbed through the level of the B737 with minimum lateral separation, 1.5 minutes earlier.
B733, Nashville TN USA, 2015 On 15 December 2015, a Boeing 737-300 crew inadvertently taxied their aircraft off the side of the taxiway into a ditch whilst en route to the gate after landing at Nashville in normal night visibility. Substantial damage was caused to the aircraft after collapse of the nose landing gear and some passengers sustained minor injuries during a subsequent cabin crew-initiated evacuation. The Investigation found that taxiing had continued when it became difficult to see the taxiway ahead in the presence of apron lighting glare after all centreline and edge lighting in that area had been inadvertently switched off by ATC.
B733, Nottingham East Midlands, UK 2006 On 15 June 2006 a TNT Belgium-operated Boeing 737-300 on diversion to East Midlands because of poor destination weather made an unintended ground contact 90 metres to one side of the intended landing runway whilst attempting to initiate a go around after a mis-flown daylight Cat 3A ILS approach. The RH MLG assembly broke off before the aircraft left the ground again and climbed away after which it was then flown to nearby Birmingham for a successful emergency landing. The subsequent investigation attributed the poor aircraft management which led to the accident to pilot distraction.
B733, Paris CDG France, 2011 On 23 July 2011, a Boeing 737-300 being operated by Jet2.com on a passenger flight from Leeds/Bradford to Paris CDG experienced violent vibration from the main landing gear at touch down in normal day visibility on runway 27R at a normal speed off a stabilised approach. This vibration was accompanied by lateral acceleration that made directional control difficult but the aircraft was kept on the runway and at a speed of 75 knots, the vibrations abruptly stopped. Once clear of the runway, the aircraft was stopped and the engines shutdown prior to a tow to the gate. None of the 133 occupants were injured.
B733, Singapore Changi Singapore, 2020 On 28 November 2020, a Boeing 737-300F taxiing for an early morning departure at Singapore Changi crossed an illuminated red stop bar in daylight and entered the active runway triggering an alert which enabled the controller to instruct the aircraft to immediately exit the runway and allow another aircraft already on approach to land. The Investigation found that the flight was the final one of a sequence of six carried out largely overnight as an extended duty predicated on an augmented crew. The context for the crew error was identified as a poorly managed operator subject to insufficient regulatory oversight.
B733, Tabing Padang Indonesia, 2012 On 13 October 2012, the crew of a Boeing 737-300 destined for the new Padang airport at Minangkabau inadvertently landed their aircraft on runway 34 at the old Padang Airport at Tabing which has a similarly-aligned runway. The Investigation found that the Captain disregarded ILS indications for the correct approach after visually acquiring the similarly aligned runway when the correct runway was not also in sight. Since the chosen runway was some 6 miles ahead of the intended one, a high descent rate achieved through sideslip, followed with this unstable approach, continued to an otherwise uneventful landing.
B733, vicinity Belfast Aldergrove UK, 2006 On 18 July 2006, a Boeing 737-300 being operated by a Spanish Airline commenced a daylight non precision approach with a 12 degree offset FAT towards Belfast Aldergrove but then made an unstable descent to 200 feet agl towards an unlicensed runway at a different airport before being told by ATC radar to go around. A further also unstable approach to the correct airport/runway followed. The Investigation noted that there were multiple cues indicating that an approach to the wrong airport was being made and was not able to establish any reason why two successive unstable approaches were not discontinued
B733, vicinity Bournemouth UK, 2007 On 23 September 2007, the pilots of a Thomsonfly Boeing 737-300 almost lost control of their aircraft after initiating a go around from an unstable low airspeed and low thrust condition reached progressively but unnoticed during an approach to Bournemouth at night. Mismanagement of the aircraft during the go around was attributed to a lack of adequate understanding of the aircraft pitch control system and led to extreme pitch and an aerodynamic stall but the crew subsequently recovered control of the aircraft and an uneventful second approach and normal landing followed.
B733, vicinity Chambery France, 2010 On 7 February 2010, a Boeing 737-300 being operated by Jet2 on a scheduled passenger flight from Leeds/Bradford UK to Chambery France was making an ILS approach to runway 18 at destination in day IMC when a Mode 2 EGPWS Terrain, Pull Up Warning occurred. A climb was immediately initiated to VMC on top and a second ILS approach was then made uneventfully. Despite extreme pitch during the early stages of the pull up climb, none if the 109 occupants, all secured for landing, were injured.
B733, vicinity Helsinki Finland, 2008 On 26 March 2008, a Ukraine International Airlines Boeing 737-300 being vectored by ATC to the ILS at destination Helsinki in IMC descended below its cleared altitude and came close to a telecommunications mast. ATC noticed the deviation and instructed a climb. The investigation attributed the non-compliance with the accepted descent clearance to the failure of the flight crew to operate in accordance with SOPs. It was also noted that the way in which ATC safety systems were installed and configured at the time of the occurrence had precluded earlier ATC awareness of the hazard caused by the altitude deviation.
B733, vicinity Kosrae Micronesia, 2015 On 12 June 2015, a Boeing 737-300 crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing. The Investigation noted failure to action the approach checklist, the absence of ATC support and the step-down profile promulgated for the NDB/DME procedure flown as well as the potential effect of fatigue on the Captain.
B733, vicinity Montpelier, France 2011 On 10 January 2011, a Europe Airpost Boeing 737-300 taking off from Montpelier after repainting had just rotated for take off when the leading edge slats extended from the Intermediate position to the Fully Extended position and the left stick shaker was activated as a consequence of the reduced stalling angle of attack. Initial climb was sustained and soon afterwards, the slats returned to their previous position and the stick shaker activation stopped. The unexpected configuration change was attributed to paint contamination of the left angle of attack sensor, the context for which was inadequate task guidance.
B733, vicinity Sharm El-Sheikh Egypt, 2004 On 3 January 3 2004, a Boeing 737-300 being operated by Flash Airlines on a passenger charter flight from Sharm el-Sheikh Egypt to Cairo for a refuelling stop en route to Paris CDG crashed into the sea 2½ minutes after a night take off into VMC and was destroyed and all 148 occupants killed. The Investigation was unable to establish a Probable Cause but found evidence of AP status confusion and the possibility of distraction leading to insufficient attention being paid to flight path control.
B733, Wamena Papua Indonesia, 2016 On 13 September 2016, a Boeing 737-300 made an unstabilised approach to Wamena and shortly after an EGPWS ‘PULL UP’ warning due to the high rate of descent, a very hard landing resulted in collapse of the main landing gear, loss of directional control and a lateral runway excursion. The Investigation found that the approach had been carried out with both the cloudbase and visibility below the operator-specified minima and noted that the Captain had ignored a delayed go around suggestion from the First Officer because he was confident he could land safely as the two aircraft ahead had done.
B733, Yogyakarta Indonesia, 2011 On 20 December 2011, the experienced Captain of a Sriwijaya Air Boeing 737-300 flew an unstabilised non-precision approach to a touchdown at Yogyakarta at excessive speed whilst accompanied by a very inexperienced First Officer. The aircraft overran the end of the 2200 metre-long wet runway by 75 metres . During the approach, the Captain 'noticed' several GPWS PULL UP Warnings but no action was taken. The Investigation attributed the accident entirely to the actions of the flight crew and found that there had been no alert calls from the First Officer in respect of the way the approach was flown.
B734 / C172, vicinity Girona Spain, 2016 On 28 September 2016, a Boeing 737-400 and a Cessna 172 both on IFR Flight Plans came into close proximity when about to turn final on the same non-precision approach at Girona from different initial joining routes. The Investigation found that two ACC sector controllers had issued conflicting approach clearances after losing situational awareness following a routine sector split due to an area ATC flow configuration change. The detection of the consequences of their error had then been hindered by a temporary area low level radar outage but helped by timely visual acquisition by both aircraft and a TCAS RA.
B734 / MD81, en-route, Romford UK, 1996 On 12 November 1996, a B737-400 descended below its assigned level in one of the holding patterns at London Heathrow in day IMC to within 100 feet vertically and between 680 and 820 metres horizontally of a MD-81 at its correct level, 1000 feet below. STCA prompted ATC to intervene and the 737 climbed back to its cleared level. Neither aircraft was fitted with TCAS 2 or saw the other visually.
B734 / Vehicle, Porto Portugal, 2021 On 27 April 2021, a Boeing 737-400 commenced a night takeoff at Porto in good visibility without seeing a runway inspection vehicle heading in the opposite direction on the same runway. On querying sight of an opposite direction aircraft on a discrete frequency the driver was told to quickly vacate the runway. The aircraft became airborne 300 metres before reaching the vehicle and passed over and abeam it. Both vehicle and aircraft were following the controller’s clearances. The detailed Investigation confirmed controller error in a context of multiple systemic deficiencies in the delivery of runway operational safety at the airport.
B734, Aberdeen UK, 2005 Significant damage was caused to the tailplane and elevator of a Boeing 737-400 after the pavement beneath them broke up when take off thrust was applied for a standing start from the full length of the runway at Aberdeen. Although in this case neither outcome applied, the Investigation noted that control difficulties consequent upon such damage could lead to an overrun following a high speed rejected takeoff or to compromised flight path control airborne. Safety Recommendations on appropriate regulatory guidance for marking and construction of blast pads and on aircraft performance, rolling take offs and lead-on line marking were made.
B734, Amsterdam Netherlands, 2010 (1) On 6 June 2010, a Boeing 737-400 being operated by Atlas Blue, a wholly owned subsidiary of Royal Air Maroc, on a passenger flight from Amsterdam to Nador, Morocco encountered a flock of geese just after becoming airborne from runway 18L in day VMC close to sunset and lost most of the thrust on the left engine following bird ingestion. A MAYDAY was declared and a minimal single engine climb out was followed by very low level visual manoeuvring not consistently in accordance with ATC radar headings before the aircraft landed back on runway 18R just over 9 minutes later.
B734, Amsterdam Netherlands, 2010 (2) On 2 October 2010 a Boeing 737-400 being operated by Turkish operator Corendon Airlines on a passenger flight from Dalaman to Amsterdam made a late touchdown on landing runway 22 at destination in normal daylight visibility conditions and failed to stop before the end of the runway. The overrun occurred at low speed and there were no injuries to the 173 occupants and only minor damage to the aircraft.
B734, East Midlands UK, 2021 On 16 June 2021, a Boeing 737-400 was taxiing for departure at night after push back from stand when the ground crew who completed the push back arrived back at their base in the tug and realised that the tow bar they had used was not attached to it. The aircraft was prevented from taking off and it was then found that it had taxied over the unseen towbar and sustained damage to both nose gear tyres such that replacement was necessary. The Investigation concluded neither ground crew had checked that the area immediately ahead of the aircraft was clear.
B734, en-route, Daventry UK, 1995 On 23 February 1995, a British Midland Boeing 737-400 made an emergency landing at Luton airport UK after losing most of the oil from both engines during initial climb out from East Midlands airport UK, attributed to failures in the quality of maintenance work and procedures during routine inspections of both engines prior to the flight.
B734, en-route, east northeast of Tanegashima Japan, 2015 On 30 June 2015, both bleed air supplies on a Boeing 737-400 at FL370 failed in quick succession resulting in the loss of all pressurisation and, after making an emergency descent to 10,000 feet QNH, the flight was continued to the planned destination, Kansai. The Investigation found that both systems failed due to malfunctioning pre-cooler control valves and that these malfunctions were due to a previously identified risk of premature deterioration in service which had been addressed by an optional but recommended Service Bulletin which had not been taken up by the operator of the aircraft involved.
B734, en-route, eastern England UK, 2018 On 12 October 2018, the crew of a Boeing 737-400 already released to service under MEL conditions with an inoperative No 1 engine generator encountered a loss of services from the No 2 electrical system en-route to East Midlands which created a situation not addressed by QRH procedures. The flight was completed and both the new and existing defects were subsequently rectified relatively easily. The Investigation concluded that the operator involved appeared to be prioritising operational requirements over aircraft serviceability issues and made a range of Safety Recommendations aimed at improving company safety culture and the effectiveness of regulatory oversight.
B734, en-route, New South Wales Australia, 2007 On 11 August 2007, a Qantas Boeing 737-400 on a scheduled passenger service from Perth, WA to Sydney, NSW was about three quarters of the way there in day VMC when the master caution light illuminated associated with low output pressure of both main tank fuel pumps. The flight crew then observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position. The flight was completed without further event.
B734, Exeter UK, 2021 On 19 January 2021, a Boeing 737-400SF on an ILS approach to Exeter became unstabilised below 500 feet but despite multiple EGPWS ‘SINK RATE’ Alerts, a go-around was not initiated. The subsequent touchdown recorded 3.8g and caused such extensive damage that the aircraft was declared a hull loss. The Investigation found that the First Officer, who had more hours flying experience than the 15,000 hour Captain, had failed to adequately control the flight path below 500 feet and noted that whilst the Captain had commented on the excessive rate of descent, he had not called for a go around.
B734, Kabul Afghanistan, 2016 On 10 December 2016, a Boeing 737-400 main gear leg collapsed on landing after an approach at excessive speed was followed by a prolonged float prior to touchdown on the high-altitude Kabul runway. The Investigation found that the collapse had followed a severe but very brief wheel shimmy episode in the presence of a number of factors conducive to this risk which the aircraft operator s pilots had not been trained to avoid. It was also found that although the aircraft operator regularly undertook wet lease contract flying, their pilot training policy did not include any route or aerodrome competency training.
B734, Lahore Pakistan, 2015 On 3 November 2015, a Boeing 737-400 continued an unstabilised day approach to Lahore. When only the First Officer could see the runway at MDA, he took over from the Captain but the Captain took it back when subsequently sighting it. Finally, the First Officer took over again and landed after recognising that the aircraft was inappropriately positioned. Both main gear assemblies collapsed as the aircraft veered off the runway. The Investigation attributed the first collapse to the likely effect of excessive shimmy damper play and the second collapse to the effects of the first aggravated by leaving the runway.
B734, Palembang Indonesia, 2008 On 2 October 2008, a Boeing 737-400 being used for flight crew command upgrade line training unintentionally landed off a non precision approach at Palembang in daylight on a taxiway parallel to the landing runway. Neither pilot realised their error until the aircraft was already on the ground when they saw a barrier ahead and were able to brake hard to stop only 700 metres from touchdown. It was found that the taxiway involved had served as a temporary runway five years earlier and that previously obliterated markings from that use had become visible.