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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Showing below 1340 results in range #1101 to #1200.

F

F16 / C150, vicinity Berkeley County SC USA, 2015 On 7 July 2015, a mid-air collision occurred between an F16 and a Cessna 150 in VMC at 1,600 feet QNH in Class E airspace north of Charleston SC after neither pilot detected the conflict until it was too late to take avoiding action. Both aircraft subsequently crashed and the F16 pilot ejected. The parallel civil and military investigations conducted noted the limitations of see-and-avoid and attributed the accident to the failure of the radar controller working the F16 to provide appropriate timely resolution of the impending conflict.

F27, vicinity Guernsey Channel Islands, 1999 On 12 January 1999, control of a Fokker F27-600 was lost on approach to Guernsey Airport, Channel Islands, as a consequence of the aircraft being operated outside the load and balance limitations.

F27, vicinity Jersey Channel Islands, 2001 Shortly after take-off from Jersey Airport, Channel Islands, a F27 experienced an uncontained engine failure and a major fire external to the engine nacelle. The fire was extinguished and the aircraft landed uneventfully back at Jersey.

F27, vicinity Sharjah UAE, 2004 On 10 February 2004, a Fokker F27 operated by Kish Airlines, crashed on approach to Sharjah, UAE, as a result of loss of control caused by selection of both propellers to the ground range in flight.

F28, Gällivare Sweden, 2016 On 6 April 2016, a Romanian-operated Fokker F28 overran the runway at Gällivare after a bounced night landing. There were no occupant injuries and only slight aircraft damage. The Investigation concluded that after a stabilised approach, the handling of the aircraft just prior and after touchdown, which included late and inappropriate deployment of the thrust reversers, was not compatible with a safe landing in the prevailing conditions, that the crew briefing for the landing had been inadequate and that the reported runway friction coefficients were probably unreliable. Safety Recommendations were made for a generic 'Safe Landing' concept to be developed.

F28, Saint John NB Canada, 2002 On 27 March 2002, a Fokker F28 being operated by Air Canada Regional Airlines (t/a Air Canada Jazz) on a scheduled night passenger flight from Toronto to Saint John, having made an uneventful procedural ILS approach to Runway 05 at destination, departed the slippery landing runway to the left shortly after touchdown in normal visibility conditions but regained it before coming to a stop. Aircraft damage was limited to minor cuts in the tyres of the right main and nose landing gear and damage to one runway edge light. There were no injuries to any of the occupants.

F2TH / GLID, vicinity St Gallen-Altenrhein Switzerland, 2017 On 15 October 2017, a Falcon 2000EX on base leg for an easterly ILS approach at St Gallen-Altenrhein came into close proximity with a reciprocal track glider at 5000 feet QNH in Class ‘E’ airspace in day VMC with neither aircraft seeing the other until just before their minimum separation - 0.35 nm horizontally and 131 feet vertically - occurred. The Investigation attributed the conflict to the lack of relevant traffic separation requirements in Class E airspace and to the glider not having its transponder switched on and not listening out with the relevant ATC Unit.

F50 / P28T, vicinity Friedrichshafen Germany, 2016 On 21 April 2016, a Fokker F50 under radar control in Class ‘E’ airspace was almost in collision with a VFR Piper PA28 after they closed on a constant relative bearing when inbound to Friedrichshafen in VMC. After only being able to locate the PA28 on their TCAS display, the F50 crew implemented a lateral avoidance manoeuvre which prevented generation of an RA. The Investigation concluded that special ATC procedures in place due to busy traffic because of an annually-held trade fair at Friedrichshafen had entailed “systemic risk” and also identified inadequate controller coordination as contributory to a near collision.

F50 / T6, vicinity Maastricht Netherlands, 2007 On 2 August 2007, a Fokker F50 on an ILS approach to Maastricht in IMC came into close proximity inside the CTZ with an unseen light aircraft which had failed to comply with its Special VFR transit clearance. The Investigation found that the transiting aircraft had come within 0.14nm / 260 metres of the opposite direction F50 at a similar altitude without either aircraft having sight of the other, and that the Harvard had been wrongly assumed by ATC to be a helicopter after an initial lack of call sign prefix clarity on first contact had not been positively resolved.

F50, Groningen Netherlands, 2007 On 18 May 2007, a Fokker 50 being operated by Belgian airline VLM on a passenger flight from Amsterdam to Groningen landed long and at excessive speed after a visual day approach to runway 05 at destination and ran off the end of the runway onto grass. None of the 14 occupants were injured and the aircraft suffered only minor damage with two runway lights being damaged.

F50, Isle of Man, 2009 On 15 January 2009 a VLM Fokker 50 left the side of the runway at the Isle of Man during the daylight landing roll. It was concluded that directional control had been lost on the wet runway because the crew had attempted rudder steering whilst also applying reverse pitch, an action which was contrary to SOPSs.

F50, vicinity Luxembourg, 2002 On 6 November 2002, a Fokker 50 operated by Luxair, crashed on approach to Luxembourg Airport following loss of control attributed to intentional operation of power levers in the ground range, contrary to SOPs.

F50, vicinity Nairobi Kenya, 2014 On 2 July 2014, a Fokker 50 fully loaded - and probably overloaded - with a cargo of qat crashed into a building and was destroyed soon after its night departure from Nairobi after failing to climb due to a left engine malfunction which was evident well before V1. The Investigation attributed the accident to the failure of the crew to reject the takeoff after obvious malfunction of the left engine soon after they had set takeoff power which triggered a repeated level 3 Master Warning that required an automatic initiation of a rejected takeoff.

F70, vicinity Munich Germany, 2004 On 5 January 2004, a Fokker 70, operated by Austrian Airlines, carried out a forced landing in a field 2.5 nm short of Munich Runway 26L following loss of thrust from both engines due to icing.

F900 / B772, en-route, near Kihnu Island Estonia, 2013 On 17 October 2013, a Falcon 900 climbing as cleared to FL 340 and being operated as a State Aircraft equipped with TCAS II v7.0 initially responded to a TCAS RA against crossing traffic at FL 350 in day VMC in the opposite direction to the one directed and prescribed separation was lost as a result. The Investigation concluded that the F900 crew had commenced a climb on receipt of a TCAS RA 'ADJUST VERTICAL SPEED' when a reduction in the 800 fpm rate of climb was required. Safety Recommendations were made in respect of TCAS RA requirements for State Aircraft.

F900, en-route, South of Bucharest Romania, 1999 On 14 September 1999, a F900 was subjected to rapid and violent vertical load oscillations, which killed most of the passengers, after incorrect crew response to a minor pitch control malfunction.

FA20, Durham Tees Valley UK, 2012 On 9 August 2012, a serviceable Cobham Leasing Fan Jet Falcon overran the 2291 metre long runway at Durham Tees Valley after beginning rejecting take off from above V1 because of a suspected bird strike. The crew believed there was a possibility of airframe damage from a single medium sized bird sighted ahead which might have been hit by the main landing gear. It was found that the overrun distance had been increased by low friction on the stopway and noted that the regulatory exemption issued for operation without FDR and CVR was no longer appropriate.

FA20, vicinity Kish Island Iran, 2014 On 3 March 2014, a Dassault Falcon 20 engaged in navigation aid calibration for the Regulator was flown into the sea near Kish Island in dark night conditions. The Investigation concluded that the available evidence indicated that the aircraft had been inadvertently flown into the sea as the consequence of the crew experiencing somatogravic illusion. It was also noted that the absence of a functioning radio altimeter and pilot fatigue attributable to the long duty period was likely to have exacerbated the pilots' vulnerability to this illusion.

FA20, vicinity Narsarsuaq Greenland, 2001 On 5 August 2001, a Dassault Falcon 20 with an inoperative GPWS making a night approach to Narsarsuaq by visual reference impacted terrain 4.5 nm from the aerodrome. The Investigation noted the original crew intention to fly a non-precision instrument approach and attributed the accident to the failure of the crew to follow applicable procedures or engage in meaningful CRM as well as to deficiencies in the Operator's required procedures which had combined to leave the crew vulnerable to a 'black hole' effect. The effects of fatigue were considered likely to have been contributory.

FA50 / Vehicle, Moscow Vnukovo Russia, 2014 On 20 October 2014 a Dassault Falcon 50 taking off at night from Moscow Vnukovo collided with a snow plough which had entered the same runway without clearance shortly after rotation. Control was lost and all occupants died when it was destroyed by impact forces and post crash fire. The uninjured snow plough driver was subsequently discovered to be under the influence of alcohol. The Investigation found that the A-SMGCS effective for over a year prior to the collision had not been properly configured nor had controllers been adequately trained on its use, especially its conflict alerting functions.

FA50, vicinity London City UK, 2010 On 21 January 2010, a Mystere Falcon 50 being operated by TAG Aviation on a positioning flight from Biggin Hill to London City in day VMC began a descent at a high rate below its cleared altitude of 2000 ft amsl because the aircraft commander believed, on the basis of external visual cues, that the aircraft was on a final approach track for Runway 27 at destination when in fact it was downwind for Runway 09. After an alert from ATC as the aircraft passed 900 ft agl at a rate of descent of approximately 2200 fpm, recovery to a normal landing on Runway 09 was achieved.

FA7X, en-route, north east of Kuala Lumpur Malaysia, 2011 On 24 May 2011, a sudden uncommanded maximum upward deflection of the trimmable horizontal stabiliser occurred to a descending Dassault Falcon 7X. Automatic opposite elevator movement did not resolve the situation and an upset lasting just over 2½ minutes followed with a 9,500 feet climb at up to 41° pitch and a speed drop to 125KCAS. Only autonomous return of normal pitch response ended the control difficulty. The remainder of the flight was without further event. A single suddenly defective component with no effective crew response available and not anticipated during type certification was found to have caused the runaway.

FA7X, London City UK, 2016 On 24 November 2016, a Dassault Falcon 7X being marshalled into an unmarked parking position after arriving at London City Airport was inadvertently directed into a collision with another crewed but stationary aircraft which sustained significant damage. The Investigation found that the apron involved had been congested and that the aircraft was being marshalled in accordance with airport procedures with wing walker assistance but a sharp corrective turn which created a 'wing growth' effect created a collision risk that was signalled at the last minute and incorrectly so by the wing walker involved and was also not seen by the marshaller.

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G115 / G115, near Porthcawl South Wales UK, 2009 On 11 February 2009, the plots of two civil-registered Grob 115E Tutors being operated for the UK Royal Air Force (RAF) and both operating from RAF St Athan near Cardiff were conducting Air Experience Flights (AEF) for air cadet passengers whilst in the same uncontrolled airspace in day VMC and aware of the general presence of each other when they collided. The aircraft were destroyed and all occupants killed

G115 / GLID, en-route Oxfordshire UK, 2009 On 14 June 2009, a Grob 115E Tutor being operated by the UK Royal Air Force (RAF) and based at RAF Benson was conducting aerobatics in uncontrolled airspace near Drayton, Oxfordshire in day VMC when it collided with a Standard Cirrus Glider on a cross country detail from Lasham. The glider was sufficiently damaged that it could no longer be controlled and the glider pilot parachuted to safety. The Tutor entered a spin or spiral manoeuvre which it exited in a steep dive from which it did not recover prior to a ground impact which killed both occupants.

G73T, vicinity Miami Seaplane Base FL USA, 2005 On 19 December 2005, a Grumman Turbo Mallard Sea Plane suffered a loss of control following the in-flight separation of the right hand wing, Miami Port, Florida, USA.

GALX, en-route, North East of Newfoundland, Canada, 2007 On 8 February 2007, A Gulfstream G-200 on an eastbound transatlantic delivery flight being undertaken by its operator entered a high altitude stall resulting from crew flight planning errors after which flight at an altitude incompatible with the performance limits of the aircraft as loaded was attempted. The crew response to this situation was confused but eventually, recovery to controlled flight was achieved. The Investigation attributed the event to lack of flight crew understanding of the core principles of flight at high altitude.

GL5T, Fox Harbour NS Canada, 2007 On 11 November 2007, a Bombardier BD-700 (Global 5000) operated by Canadian charter company Jetport touched down short of the runway at destination Fox Harbour in normal daylight visibility and then directional control was lost and the aircraft exited the side of the runway ending up having rotated 120° clockwise about its fore-aft axis and came to rest approximately 300metres from the threshold and approximately 50 meters from the runway edge. As a result, the co pilot and one of the passengers suffered serious injuries and the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.

GLEX, Biggin Hill UK, 2020 On 17 September 2020, a Bombardier Global 6000 which had completed a circling approach to land at Biggin Hill in day VMC touched down with an inappropriate pitch and roll attitude which caused the right wingtip to contact the runway surface. The Investigation found that the landing technique just before touchdown was not in accordance with the manufacturer’s crosswind landing technique although the roll rate achieved could not be accounted for by the roll control input alone and was probably increased by localised wind velocity variations despite the absence of any such variations being reported by ATC.

GLEX, Liverpool UK, 2019 On 11 December 2019, a Bombardier BD700 Global 6000 making a night landing at Liverpool suffered a nose wheel steering failure shortly after touchdown. The crew were unable to prevent the aircraft departing the side of the runway into a grassed area where it stopped, undamaged, in mud. The Investigation found that the crew response was contrary to that needed for continued directional control but also that no pilot training or QRH procedure covered such a failure occurring at high speed nor was adequate guidance available on mitigating the risk of inadvertent opposite brake application during significant rudder deflection.

GLEX, Luton UK, 2008 On 29 January 2008, a Bombardier BD700 Global Express on a private passenger flight from Van Nuys, California to Luton experienced a single tyre failure when landing at destination in normal day visibility which caused significant secondary damage to the flight control system and localised structural damage to the wing. The aircraft was stopped on the runway and there were no injuries to the four occupants.

GLEX, Montréal St Hubert Canada, 2017 On 15 May 2017, a Bombardier Global Express crew failed to land on the restricted runway width available at Montréal St Hubert where there was a long-term construction project which had required reductions in both width and length of the main runway. The Investigation found that relevant NOTAM information including a requirement to pre-notify intended arrival had been ignored and that during arrival the crew had failed to respond to a range of cues that their landing would not be on the normally-available runway. Deficiencies in the arrangements made for continued use of part of the runway were also identified.

GLEX, Prestwick UK, 2014 On 6 March 2014, a Bombardier Global 6000 being landed by a pilot using a HUD at night was mishandled to the extent that one wing was damaged by ground contact due to excessive pitch just before touchdown. During the Investigation, a Global 6000 operated by a different operator was similarly damaged during a night landing. The Investigation discovered that relevant operational documentation was inconsistent and pilot training had (in both cases) been inappropriate. These issues were resolved by a combination of aircraft manufacturer and aircraft operator action

GLEX/F2TH, vicinity Ibiza Spain, 2012 On 21 September 2012, two aircraft came into conflict in Class 'A' airspace whilst under radar control at night and loss of separation was resolved by TCAS RA responses by both aircraft. Investigation found that one of the aircraft had passed a procedurally-documented clearance limit without ATC clearance or intervention and that situational awareness of its crew had been diminished by communications with the conflicting aircraft being conducted in Spanish rather than English. A Safety Recommendation on resolving the persistent problem of such language issues was made, noting that a similar recommendation had been made 11 years earlier.

GLF3, Biggin Hill UK, 2014 On 24 November 2014, the crew of a privately-operated Gulfstream III carrying five passengers inadvertently commenced take off at night in poor visibility when aligned with the runway edge instead of the runway centreline. When the aircraft partially exited the paved surface, the take-off was rejected but not before the aircraft had sustained substantial damage which put it beyond economic repair. The Investigation found that chart and AIP information on the taxiway/runway transition made when lining up was conducive to error and that environmental cues, indicating the aircraft was in the wrong place to begin take-off, were weak.

GLF4, Abuja Nigeria, 2018 On 12 September 2018, a Gulfstream G-IV overran the runway at Abuja after the air/ground status system failed to transition to ground on touchdown and the crew were slow to recognise that as a result neither spoilers nor thrust reversers had deployed. In the absence of recorded flight data, it was not possible to establish why the air/ground sensing system did not transition normally but no fault was found. The aircraft operator’s procedures in the event of such circumstances were found to be inadequate and regulatory oversight of the operator to have been comprehensively deficient over an extended period.

GLF4, Bedford MA USA, 2014 On 31 May 2014, a Gulfstream IV attempted to take off with the flight control gust locks engaged and, when unable to rotate, delayed initiating the inevitable rejected take off to a point where an overrun at high speed was inevitable. The aircraft was destroyed by a combination of impact forces and fire and all seven occupants died. The Investigation attributed the accident to the way the crew were found to have habitually operated but noted that type certification had been granted despite the aircraft not having met requirements which would have generated an earlier gust lock status warning.

GLF4, Berlin Tegel Germany, 2007 A Gulfstream 4 departing from Berlin at night with good surface visibility prevailing was cleared to taxi onto the parallel runway beyond the one in use for landing because both the GND and TWR controllers had incorrectly assumed the original parking position of the aircraft. Upon approaching the runway crossing, the Gulfstream 4 crew recognised a stream of approaching aircraft and held clear whilst (with difficulty) alerting the TWR controller to their implied crossing clearance. At this point the controller recognised the ATC error.

GLF4, Le Castellet France, 2012 On 13 July 2012, a Gulfstream G-IV left the side of the runway at high speed during the landing roll at Le Castellet following a positioning flight after ineffective deceleration after the flight crew had forgotten to arm the ground spoilers. The Investigation found that pilot response to this situation had been followed by a loss of directional control, collision with obstructions and rapid onset of an intense fire. Contributory factors identified included poor procedural compliance by the pilots, their lack of training on a relevant new QRH procedure which Gulfstream had ineffectively communicated and ineffective FAA oversight of the operation.

GLF4, Teterboro NJ USA, 2010 On 1 October 2010, a Gulfstream G-IV being operated by General Aviation Flying Service as ‘Meridian Air Charter’ on a corporate flight from Toronto International to Teterboro made a deep landing on 1833m-long runway 06 at destination in normal day visibility and overran the end of the runway at a speed of 40 to 50 knots before coming to a stop 30m into a 122m long EMAS installation.

GLF4, vicinity Kerry Ireland, 2009 On 13 July 2009, a Gulfstream IV being operated by Indian operator Asia Aviation on a private flight from Kerry to Luton with one passenger on board in day IMC suffered a left main windshield failure shortly after take off and elected to make a return to land. Having received an ATC clearance to do so, it then failed to follow it and began a steep descent approximately 6 nm to the south of the airport towards high ground. When ATC became aware of this, an urgent instruction to climb was given and eventually the return was completed.

GLF5 / A319, south-eastern France, 2004 On 16 September 2004, a loss of separation occurred over Geneva between Air France A319 and a Gulfstream 5 which commenced descent without clearance by ATC and with coordinated TCAS RAs not followed by either aircraft.

GLF5, vicinity Hong Kong China, 2015 On 13 January 2015, a Gulfstream G550 approaching Hong Kong on a positioning flight suddenly began rapidly descending without clearance and came within 500 feet of the sea surface before a recovery triggered by an EGPWS ‘PULL UP’ Warning had been accomplished. The Investigation found that the excursion resulted from an inadvertent and unrecognised elevator trim switch input which caused the autopilot to disconnect and that initiation of a recovery was delayed by the continued failure of all three pilots on the flight deck to determine the control status of the aircraft and was hindered by their ineffective CRM.

GLF6, Roswell NM USA, 2011 On 2 April 2011, the crew of a Gulfstream G650 undertaking a pre-type certification experimental test flight take off with one engine intentionally inoperative were unable to recover controlled flight after a wing drop occurred during take off. The aeroplane impacted the ground without becoming properly airborne and was destroyed by a combination of the impact and a post crash fire with fatal injuries to all four occupants. The subsequent Investigation found that preparation for the flight had been inadequate and had failed to incorporate effective response to previous similar incidents where recovery had been successful.

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H25B / AS29, en-route / manoeuvring, near Smith NV USA, 2006 On 28 August 2006, a Hawker 800 collided with a glider at 16,000 feet in Class 'E' airspace. The glider became uncontrollable and its pilot evacuated by parachute. The Hawker was structurally damaged and one engine stopped but it was recovered to a nearby airport. The Investigation noted that the collision had occurred in an area well known for glider activity in which transport aircraft frequently avoided glider collisions using ATC traffic information or by following TCAS RAs. The glider was being flown by a visitor to the area with its transponder intentionally switched off to conserve battery power.

H25B / B738, en-route, south eastern Senegal, 2015 On 5 September 2015, a Boeing 737-800 cruising as cleared at FL350 on an ATS route in daylight collided with an opposite direction HS 125-700 which had been assigned and acknowledged altitude of FL340. The 737 continued to destination with winglet damage apparently causing no control impediment but radio contact with the HS 125 was lost and it was subsequently radar-tracked maintaining FL350 and continuing westwards past its destination Dakar for almost an hour before making an uncontrolled descent into the sea. The Investigation found that the HS125 had a recent history of un-rectified altimetry problems which prevented TCAS activation.

H25B, Mykonos Greece, 2017 On 26 July 2017, a Hawker Beechcraft 850 left wing sustained extensive damage when it contacted the runway at Mykonos during a 2.7g touchdown after an unstabilised approach in benign weather conditions had been continued. The Investigation found that the aircraft was airworthy prior to a temporary loss of control at touchdown which occurred after stick pusher activation due to the airspeed being more than 20 knots below the applicable reference speed and only three knots above the applicable stall speed. The monitoring of the First Officer’s approach by the Captain was minimal and late with few alert calls given.

H25B, vicinity Akron OH USA, 2015 On 10 November 2015, the crew of an HS 125 lost control of their aircraft during an unstabilised non-precision approach to Akron when descent was continued below Minimum Descent Altitude without the prescribed visual reference. The airspeed decayed significantly below minimum safe so that a low level aerodynamic stall resulted from which recovery was not achieved. All nine occupants died when it hit an apartment block but nobody on the ground was injured. The Investigation faulted crew flight management and its context - a dysfunctional Operator and inadequate FAA oversight of both its pilot training programme and flight operations.

H25B, vicinity Kerry Ireland, 2015 On 16 June 2015, the crew of a US-operated HS125 on a commercial air transport flight failed to continue climbing as cleared to FL200 after take off from Kerry for a transatlantic flight and instead levelled at 2000 feet on track towards higher terrain. Prompt ATC recognition of the situation and intervention to direct an immediate climb resolved the imminent CFIT risk. The Investigation found that the two pilots involved had, despite correct readback, interpreted their clearance to flight level two hundred as being to two thousand feet and then failed to seek clarification from ATC when they became confused.

H25B, vicinity Owatonna MN USA, 2008 On 31 July 2008, the crew of an HS125-800 attempted to reject a landing at Owatonna MN after a prior deployment of the lift dumping system but their aircraft overran the runway then briefly became airborne before crashing. The aircraft was destroyed and all 8 occupants were killed. The Investigation attributed the accident to poor crew judgement and general cockpit indiscipline in the presence of some fatigue and also considered that it was partly consequent upon the absence of any regulatory requirement for either pilot CRM training or operator SOP specification for the type of small aircraft operation being undertaken.

H500 / D150, en-route, North of London UK, 2007 On 5 October 2007, a loss of separation occurred between a Hughes 369 helicopter and a Jodel D150. The incident occurred outside controlled airspace, in VMC, and the estimated vertical separation as the Jodel took avoiding action by descending, was assessed by both pilots to be less than 50 feet.

HAWK, vicinity Bournemouth, UK 2011 On 20 August 2011, a RAF Aerobatic Team Hawk failed to complete a formation break to land near Bournemouth and the aircraft flew into the ground, destroying the aircraft and killing the pilot. The subsequent Inquiry concluded that the pilot had become semi conscious as the result of the sudden onset of G-induced impairment characterised as A-LOC. It was found that the manoeuvre as flown was not radically different to usual and that the context for the accident was to be found in a range of organisational failures in risk management.

HUNT, manoeuvring, vicinity Shoreham UK, 2015 On 22 August 2015 the pilot of a civil-operated Hawker Hunter carrying out a flying display sequence at Shoreham failed to complete a loop and partial roll manoeuvre and the aircraft crashed into road traffic unrelated to the airshow and exploded causing multiple third party fatalities and injuries. The Investigation found that the pilot had failed to enter the manoeuvre correctly and then failed to abandon it when it should have been evident that it could not be completed. It was concluded that the wider context for the accident was inadequate regulatory oversight of UK civil air display flying risk management.

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IL76 / B741, en-route, west of Delhi India, 1996 On 12 November 1996, an Ilyushin IL76TD and an opposite direction Boeing 747-100 collided head on at the same level in controlled airspace resulting in the destruction of both aircraft and the loss of 349 lives. The Investigation concluded that the IL76 had descended one thousand feet below its cleared level after its crew had interpreted ATC advice of opposite direction traffic one thousand feet below as the reason to remain at FL150 as re-clearance to descend to this lower level. Fifteen Safety Recommendations relating to English language proficiency, crew resource management, collision avoidance systems and ATC procedures were made.    

IL76, St John's Newfoundland Canada, 2012 On 13 August 2012, an Ilyushin IL76 freighter overran landing runway 11 at St John's at 40 knots. The Investigation established that although a stabilised approach had been flown, the aircraft had been allowed to float in the presence of a significant tail wind component and had not finally touched down until half way along the 2590 metre long runway. It was also found that reverse thrust had then not been fully utilised and that cross connection of the brake lines had meant that the anti skid pressure release system worked in reverse sense, thus reducing braking effectiveness.

IL76, vicinity Karachi Pakistan, 2010 On 27 November 2010, collateral damage to the wing of an IL-76 in the vicinity of an uncontained engine failure, which occurred soon after take-off from Karachi, led to fuel in that wing igniting. Descent from a maximum height of 600 feet occurred accompanied by a steadily increasing right bank. Just under a minute after take-off ground impact occurred and impact forces and fire destroyed the aircraft. The Investigation concluded that the engine failure was attributable to component fatigue in the LP compressor and that it would have been impossible for the crew to retain control.

IL76, Yerevan Armenia, 2019 On 16 May 2019, an Ilyushin Il-76 overran the end of the landing runway at Yerevan after completing an ILS approach because the crew hadn’t realised until it was too late to stop that the available landing distance was reduced at the far end of the runway. The Investigation noted that it would have been possible to stop the aircraft in the distance available and attributed the lack of flight crew awareness to a combination of their own lack of professionalism and that exhibited by the Dispatcher and to the inadequacy and lack of clarity in the NOTAM communications advising the change.

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JS31, Fort St. John BC Canada, 2007 On 9 January 2007, a Peace Air British Aerospace Jetstream 31 on a scheduled service flight from Grand Prairie, Alberta made an instrument approach to Runway 29 at Fort St. John, British Columbia and touched down 320 feet short of the runway striking approach and runway threshold lights.

JS31, Kärdla Estonia, 2013 On 28 October 2013 a BAe Jetstream 31 crew failed to release one of the propellers from its starting latch prior to setting take off power and the aircraft immediately veered sharply off the side of the runway without directional control until the power levers were returned to idle. The aircraft was then steered on the grass towards the nearby apron and stopped. The Investigation found that the pilots had habitually used multiple unofficial procedures to determine propeller status prior to take off and also noted that no attempt had been made to stop the aircraft using the brakes.

JS31, Skien Norway, 2001 On 30 November 2001, a BAe Jetsream 31 operated by European Executive Express ran off the side of runway 19 on landing at Skien Airport, Geiteryggen, Norway. The runway excursion was the consequence of an unstable non-precision approach, with airframe ice accretion, and a very heavy touchdown, which caused severe aircraft damage and loss of control.

JS32, Münster/Osnabrück Germany, 2019 On 8 October 2019, a BAe Jetstream 32 departing Münster/Osnabrück couldn’t be rotated and after beginning rejected takeoff from well above V1, the aircraft departed the side of the runway passing close to another aircraft at high speed before regaining the runway for the remainder of its deceleration. The Investigation noted that the flight was the first supervised line training sector for the very inexperienced First Officer but attributed the whole event to the Training Captain’s poor performance which had, apart many from other matters, led indirectly to the inability to rotate and to the subsequent directional control problem.

JS32, Torsby Sweden, 2014 On 31 January 2014, an Estonian-operated BAE Jetstream 32 being used under wet lease to fulfil a government-funded Swedish domestic air service requirement landed long at night and overran the end of the runway. The Investigation concluded that an unstabilised approach had been followed by a late touchdown at excessive speed and that the systemic context for the occurrence had been a complete failure of the aircraft operator to address operational safety at anything like the level appropriate to a commercial operation. Failure of the responsible State Safety Regulator to detect and act on this situation was also noted.

JS41, Birmingham UK, 2007 On 26 June 2007, at Birmingham Airport UK, a BAe Jetstream 41 started an engine running pushback without using intercom between ground crew and flight crew. The pushback could not be completed as the towbar could not be disconnected and confusion over a decision to return the aircraft to the gate resulted in an attempt to do so with the aircraft brakes selected which caused the aircraft nose landing gear to collapse.

JS41, en-route, North West of Aberdeen UK, 2008 On 9 April 2008, a BAe Jetstream 41 departed Aberdeen in snow and freezing conditions after the Captain had elected not to have the airframe de/anti iced having noted had noted the delay this would incur. During the climb in IMC, pitch control became problematic and an emergency was declared. Full control was subsequently regained in warmer air. The Investigation concluded that it was highly likely that prior to take off, slush and/or ice had been present on the horizontal tail surfaces and that, as the aircraft entered colder air at altitude, this contamination had restricted the mechanical pitch control.

JS41, Rhodes Greece, 2015 On 2 February 2015, a Jetstream 41 made a hard and extremely fast touchdown at Rhodes and the left main gear leg collapsed almost immediately. The crew were able to prevent the consequent veer left from leading to a lateral runway excursion. The Investigation found that the approach had been significantly unstable throughout with touchdown at around 50 knots above what it should have been and that a whole range of relevant procedures had been violated by the management pilot who had flown the approach in wind shear conditions in which approaches to Rhodes were explicitly not recommended.

JS41, vicinity Durban South Africa, 2009 On 24 September 2009 a BAe Jetstream 41 being operated by SA Airlink on a positioning flight from Durban to Pietermaritzburg with only three crew members on board experienced an engine fire during take off and after reaching a height of about 500 feet agl then entered a semi controlled descent to a high impact forced landing in a residential area about 1400 metres beyond the runway end. The three occupants were all seriously injured and the aircraft commander subsequently died as a result of his injuries. A fourth person on the ground was also injured.

JU52, en-route, west of Chur Switzerland, 2018 On 4 August 2018, a Junkers Ju-52 making a low level sightseeing flight through the Swiss Alps crashed killing all 20 occupants after control was lost when it stalled after encountering unexceptional windshear. The Investigation found that the pilots had created the conditions which led to the stall and then been unable to recover from it and concluded that the accident was a direct consequence of their risky behaviour. It found that such behaviour was common at the operator, that the operator was being managed without any regard to operational risk and that safety regulatory oversight had been systemically deficient.

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L101, vicinity Riyadh Saudi Arabia, 1980 On 19 August 1980, a Lockheed L1011 operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia - seven minutes later an aural warning indicated a smoke in the aft cargo compartment. Despite the successful landing all 301 persons on board perished due toxic fumes inhalation and uncontrolled fire.

L188, vicinity Stansted UK, 2007 On 19 March 2007, shortly after take off from Stansted UK, the crew of a Lockheed Electra Freighter being operated by Atlantic Airways experienced control difficulties and power fluctuation on all engines, subsequently attributed to a malfunctioning propeller synchrophaser. The flight crew were unclear what was occurring and proceeded to shut down one engine and believed that the others were at risk of failure during a return to land.

L35 / EUFI, manoeuvring, Olsberg-Elpe, Germany 2014 On 23 June 2014, a civil-operated Learjet 35 taking part in a German Air Force interception training exercise collided with the intercepting fighter aircraft as it began a follow-me manoeuvre. It became uncontrollable as a result of the damage sustained in the collision and crashed into terrain, killing both pilots. The Investigation found that whilst preparation for the exercise by all involved had been in compliance with requirements, these requirements had been inadequate, especially in respect of co-ordination between all the pilots involved, with both the civil and military safety regulatory authorities failing to detect and act on this situation.

L410, Dubrovnik Croatia, 2018 On 29 November 2018, a Let 410 landed on a temporarily closed section of the runway at Dubrovnik after a visual approach in benign weather conditions. The Investigation found that the flight crew had not carried out a sufficient pre-flight review of current and available information about a major multi-phase runway reconstruction there which they were familiar with. The opportunity for better advance and real time communication with aircraft operators and their flight crew and the benefit of the recommended ‘X’ marking at the beginning of any temporarily closed part of a runway, omitted in this case, was noted.

L410, Isle of Man, 2017 On 23 February 2017, a Czech-operated Let-410 departed from Isle of Man into deteriorating weather conditions and when unable to land at its destination returned and landed with a crosswind component approximately twice the certified limit. The local Regulatory Agency instructed ATC to order the aircraft to immediately stop rather than attempt to taxi and the carrier’s permit to operate between the Isle of Man and the UK was subsequently withdrawn. The Investigation concluded that the context for the event was a long history of inadequate operational safety standards associated with its remote provision of flights for a Ticket Seller.

L410, vicinity Lukla Nepal, 2017 On 27 May 2017, a Let 410 attempting to complete a visual approach to Lukla in rapidly deteriorating visibility descended below threshold altitude and impacted terrain close to the runway after stalling when attempting to climb in landing configuration. The aircraft was destroyed by the impact and two of the three occupants fatally injured. The Investigation concluded that the Captain had lost situational awareness at a critical time and had been slow to respond to the First Officer’s alert that the aircraft was too low. Safety Recommendations included the establishment of an independent and permanent Air Accident Investigation Agency.

LJ24, vicinity Belleville Illinois USA, 2003 On November 12, 2003, a Bombardier Learjet 24D being operated on a non scheduled flight by Multi-Aero Inc. was destroyed during a forced landing and post crash fire following a loss of power in both engines after an encounter with a flock of birds just after take off from St. Louis Downtown Airport.

LJ24, vicinity Bornholm Denmark, 2012 On 15 September 2012, a Learjet 24 experienced double engine failure in daylight VMC as it positioned visually on base leg at Bornholm and an emergency was declared. The subsequent handling of the aircraft then led to a stall from which recovery was not possible and terrain impact occurred in a standing crop at low forward speed shortly after crossing the coastline. The aircraft was destroyed and both occupants seriously injured. Investigation established that the engines had stopped due to fuel starvation resulting from mismanagement of the fuel system and had been preceded by a low fuel quantity warning.

LJ25, Northolt London UK,1996 On 13 August 1996, a Bombardier Learjet 25B being operated by a Spanish Air Taxi Operator on a private charter flight from Palma de Mallorca Spain to Northolt made a high speed overrun of the end of the landing runway after an approach in day VMC and collided with traffic on a busy main road after exiting the airport perimeter. All three occupants - the two pilots and one passenger - suffered minor injuries as did the driver of a vehicle hit by the aircraft. The aircraft was destroyed by impact forces but there was no fire.

LJ35, Aberdeen SD USA, 1999 On 25 October 1999, a Learjet 35, being operated on a passenger charter flight by Sunjet Aviation, crashed in South Dakota following loss of control attributed to crew incapacitation.

LJ35, Lyon France, 2000 On 2 May 2000, the crew of a LJ35 lost control of the aircraft, as a result of incorrect manual flying inputs, and crashed just before touchdown at Lyon, following an unstable single engine approach.

LJ35, vicinity Masset BC Canada, 1995 On 11 January 1995, a Learjet 35 on a medical positioning flight and carrying a medical team crashed into the sea while conducting an NDB approach to Masset, British Columbia, Canada. The most probable cause was considered to be a miss-set altimeter.

LJ60, Columbia SC USA, 2008 On September 19 2008, a Learjet 60 departing Columbia SC USA on a non scheduled passenger overran after attempting a rejected take off from above V1 and then hit obstructions which led to its destruction by fire and the death or serious injury of all six occupants. The subsequent investigation found that the tyre failure which led to the rejected take off decision had been due to under inflation and had damaged a sensor which caused the thrust reversers to return to their stowed position after deployment with the unintended forward thrust contributing to the severity of the overrun.

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MA60, en route, west of Bima Indonesia, 2011 On 12 December 2011, the crew of a Xian MA60 delayed their response to an engine fire warning until the existence of a fire had been confirmed by visual inspection and then failed to follow the memory engine shutdown drill properly so that fire continued for considerably longer than it should have. The Investigation found that an improperly tightened fuel line coupling which had been getting slowly but progressively worse during earlier flights had caused the fire. It was also concluded that the pilots' delay in responding to the fire had prolonged risk exposure and jeopardised the safety of the flight.

MA60, Kupang Indonesia, 2013 On 10 June 2013, a Merpati Nusantara Xian MA60 flown by a First Officer undergoing supervised line training made an unstable visual approach at destination which culminated in a sudden further increase in the rate of descent. The aircraft initially touched down on the runway with a vertical acceleration of 6g and then, after a bounce of -3g, stopped in 200 metres. The impact resulted in the wing box separating from the fuselage. The Investigation found that the Power Levers had been unintentionally moved into the ground range shortly before touchdown without either pilot being aware.

MA60, vicinity Kaimana West Papua Indonesia, 2011 On 7 May 2011, the crew of a Xian MA60 lost control of their aircraft during an attempted go around at Kaimana after failing to obtain sufficient visual reference to complete the approach despite a significant violation of the minima for the required visual-only approach. The aircraft was destroyed by the high speed impact and all occupants were killed. The Investigation found that the crew had comprehensively failed to conduct the go around procedure as prescribed and it was suspected that the new-to-type Captain may have reverted to procedures for his previous jet aircraft type after ineffective type conversion training.

MD11, Dublin Ireland, 2002 On 3 February 2002, a Delta Airlines MD-11 encountered a sudden exceptional wind gust (43 kts) during the landing roll at Dublin, Ireland. The pilot was unable to maintain the directional control of the aircraft and a runway excursion to the side subsequently occurred.

MD11, en-route, Atlantic Ocean near Halifax Canada, 1998 On 2 September 1998, an MD-11 aircraft belonging to Swissair, crashed into the sea off Nova Scotia following an in-flight electrical fire.

MD11, en-route, near Cape Ashizuri, Japan, 2007 On 10 January 2007, a Transmile Air Services Boeing MD11F First Officer became suddenly incapacitated by seizure during a flight from Anchorage to Hong Kong. A diversion was made and the affected pilot hospitalised where the cause was identified as a previously non-symptomatic brain tumour.

MD11, Hong Kong China, 1999 On 22 August 1999, a Boeing MD11 being operated by China Airlines on a scheduled passenger flight from Taipei to Hong Kong carried out a normal ILS approach to Runway 25 Left in a strong crosswind and some turbulence but the night landing on a wet runway surface in normal visibility was very hard after a high sink rate in the flare was not arrested. The right main landing gear collapsed, the right wing separated from the fuselage and the aircraft caught fire and became inverted and reversed ending up on the grass to the right of the runway. Rapid attendance by the RFFS facilitated the escape of most of the 315 occupants but there were 3 deaths and 50 serious injuries as well as 153 minor injuries. The aircraft was destroyed.

MD11, New York JFK USA, 2003 A McDonnell Douglas MD11F failed to complete its touchdown on runway 04R at New York JFK until half way along the 2560 metre-long landing runway and then overran the paved surface by 73 metres having been stopped by the installed EMAS. The Investigation found no evidence that the aircraft was not serviceable and noted that the and that the landing had been attempted made with a tailwind component which meant that the runway was the minimum necessary for the prevailing aircraft landing weight.

MD11, Riyadh Saudi Arabia, 2010 On 27 July 2010, a Boeing MD11F being operated by Lufthansa Cargo on a scheduled flight from Frankfurt to Riyadh bounced twice prior to a third hard touchdown whilst attempting to land on 4205 metre-long Runway 33L at destination in normal day visibility. The fuselage was ruptured and, as the aircraft left the side of the runway, the nose landing gear collapsed and a fire began to take hold. A ‘MAYDAY’ call was made as the aircraft slid following the final touchdown. Once the aircraft had come to a stop, the two pilots evacuated before it was largely destroyed by fire. One pilot received minor injuries, the other injuries described as major.

MD11, vicinity East Midlands UK, 2005 On 3 December 2005, the crew of a MD-11 freighter failed to set the (very low) QNH for a night approach, due to distraction, and as a result descended well below the cleared altitude given by ATC for the intercept heading for the ILS at Nottingham East Midlands airport, UK.

MD81, Grenoble France, 2010 On 5 February 2010, a McDonnell Douglas MD 81 being operated by SAS on a non scheduled passenger flight from Copenhagen to Grenoble carried out a normal ILS approach to runway 09 in dark night VMC conditions, but the touchdown was made with the aircraft at an excessive pitch angle and higher than normal rate of descent and a tail strike occurred. Serious damage was caused to the rear lower fuselage but none of the 131 occupants were injured and a normal taxi-in and disembarkation followed.

MD81, Kiruna Sweden, 1997 A scheduled passenger flight from Stockholm Arlanda to Kiruna left the runway during the night landing at destination performed in a strong crosswind with normal visibility.

MD81, vicinity Chicago Midway, IL USA, 2008 On 7 July 2008, a Mc Donnell Douglas MD81 being operated by Midwest Airlines, Inc. had just taken off in day visual flight conditions when increasing pitch could initially not be controlled. Later, control was regained but with “higher than normal” pitch control pressure required to control the aircraft - after en-route diversion the aircraft landed uneventfully.

MD81, vicinity Stockholm Arlanda Sweden, 1991 On 27 December 1991, an MD-81 took off after airframe ground de/anti icing treatment but soon afterwards both engines began surging and both then failed. A successful crash landing with no fatalities was achieved four minutes after take off after the aircraft emerged from cloud approximately 900 feet above terrain. There was no post-crash fire. The Investigation found that undetected clear ice on the upper wing surfaces had been ingested into both engines during rotation and initiated engine surging. Without awareness of the aircraft's automated thrust increase system, the pilot response did not control the surging and both engines failed.

MD82 / A319, vicinity Helsinki Finland, 2007 On 5 September 2007 in day VMC, an MD82 being operated by SAS was obliged to carry out an own-initiative avoiding action orbit in day VMC against an Airbus A319 being operated by Finnair on a scheduled passenger after conflict when about to join final approach. Both aircraft were following ATC instructions which, in the case of the MD 82, had not included maintaining own separation so that the applicable separation minima were significantly breached.

MD82 / C441, Lambert-St Louis MI USA, 1994 On 22 November 1994 a McDonnell Douglas MD 82 flight crew taking off from Lambert- St. Louis at night in excellent visibility suddenly became aware of a stationary Cessna 441 on the runway ahead and was unable to avoid a high speed collision. The collision destroyed the Cessna but allowed the MD82 to be brought to a controlled stop without occupant injury. The Investigation found that the Cessna 441 pilot had mistakenly believed his departure would be from the runway he had recently landed on and had entered that runway without clearance whilst still on GND frequency.

MD82 / MD11, Anchorage AK USA, 2002 On 17 March 2002, at Ted Stevens Anchorage Airport, a McDonnell Douglas MD82 operated by Alaska Airlines, on a night pushback in snow conditions collided with an inbound taxiing McDonnell Douglas MD-11. The MD82 suffered substantial rudder damage although the impacting MD11 winglet was undamaged.

MD82, Copenhagen Denmark, 2013 On 30 January 2013, the crew of a Boeing MD82 successfully rejected its take off at Copenhagen after sudden explosive failure of the left hand JT8D engine occurred during the final stage of setting take off thrust. Full directional control of the aircraft was retained and the failure was contained, but considerable engine debris was deposited on the runway. The subsequent Investigation concluded that a massive failure within the low pressure turbine had been initiated by the fatigue failure of one blade, the reason for which could not be established.

MD82, Detroit MI USA, 1987 On 16 August 1987, an MD-82 being operated by Northwest Airlines on a scheduled passenger flight from Detroit MI to Phoenix AZ failed to get properly airborne in day VMC and, after damaging impact with obstacles within the airport perimeter after climbing to a maximum height of just under 40 ft, impacted the ground causing the destruction of the aircraft by impact forces and a subsequent fire. All but one of the 157 occupants were killed with the single survivor suffering serious injury. On the ground, 2 people were killed, 2 more seriously injured and 4 more suffered minor injury with several buildings vehicles and structures damaged or destroyed.

MD82, en route, west of Wichita KA USA, 2002 On 4 June 2002, the crew of an MD82 in the cruise at FL330 with AP and A/T engaged failed to notice progressive loss of airspeed and concurrent increase in pitch attitude as both engines rolled back to thrust levels which could not sustain level flight. The aircraft stalled and a recovery was accomplished with significant altitude necessary before engine thrust was restored and a diversion made. The Investigation attributed the engine rollback to ice crystal icing obstructing the engine inlet pressure sensors following crew failure to use the engine anti-icing as prescribed. Two Safety Recommendations were made.

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