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Risk-based Oversight demo/Ineffective Regulatory Oversight events

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Accidents and Incidents

The following events in the SKYbrary database of Accident and Incident reports feature Ineffective Regulatory Oversight as a contributory factor:

  • 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.)
  • 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rather than attempt to taxi and the carrier’s permit to operate between the Isle of Man and the UK was subsequently withdrawn.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.)
  • C402, Virgin Gorda British Virgin Islands, 2017 (On 11 February 2017, a Cessna 402 failed to stop on the runway when landing at Virgin Gorda and was extensively damaged. The Investigation noted that the landing distance required was very close to that available with no safety margin so that although touchdown was normal, when the brakes failed to function properly, there was no possibility of safely rejecting the landing or stopping normally on the runway. Debris in the brake fluid was identified as causing brake system failure. The context was considered as the Operator’s inadequate maintenance practices and a likely similar deficiency in operational procedures and processes.)
  • RJ85, vicinity Medellín International (Rionegro) Colombia, 2016 (On 29 November 2016, a BAe Avro RJ85 failed to complete its night charter flight to Medellín (Rionegro) when all engines stopped due to fuel exhaustion and it crashed in mountainous terrain 10 nm from its intended destination killing almost all occupants. The Investigation noted the complete disregard by the aircraft commander of procedures essential for safe flight by knowingly departing with significantly less fuel onboard than required for the intended flight and with no apparent intention to refuel en route. It found that this situation arose in a context of a generally unsafe operation subject to inadequate regulatory oversight.)
  • RJ1H, vicinity Gothenburg Sweden, 2016 (On 7 November 2016, severe airframe vibrations occurred to an Avro RJ-100 which, following ground de icing, was accelerating in the climb a few minutes after departing from Gothenburg. The crew were able to stop the vibrations by reducing speed but they declared an emergency and returned to land where significant quantities of ice were found and considered to have been the cause of the vibrations. The Investigation concluded that the failure of the de icing operation in this case had multiple origins which were unlikely to be location specific and generic safety recommendations were therefore made.)
  • B737, New York La Guardia USA, 2016 (On 27 October 2016, a Boeing 737-700 crew made a late touchdown on the runway at La Guardia and did not then stop before reaching the end of the runway and entered - and exited the side of - the EMAS before stopping. The Investigation concluded that the overrun was the consequence of a failure to go around when this was clearly necessary after a mishandled touchdown and that the Captain's lack of command authority and a lack of appropriate crew training provided by the Operator to support flight crew decision making had contributed to the failure to go around.)
  • C500, vicinity Kelowna BC Canada, 2016 (On 13 October 2016, a Cessna 500 crashed and was destroyed after an apparent loss of control shortly after taking off from Kelowna at night. In the absence of recorded flight data the Investigation was unable to explain the circumstances which led to loss of control but did identify significant safety concerns about both lack of progress in mandating the carriage of lightweight flight data recorders on small aircraft and a significant lack of effectiveness in the regulatory oversight of the business aviation sector in Canada.)
  • 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.)
  • E190, Kupang Indonesia, 2015 (On 21 December 2015, an Embraer 195 crew continued a significantly unstable approach which included prolonged repetition of 'High Speed' and a series of EGPWS Alerts which were both ignored and which culminated in a high speed late touchdown which ended in a 200 metre overrun. The Investigation attributed the event to poor flight management and noted the systemic lack of any effective oversight of pilot operating standards compounded in the investigated event by the effects of a steep flight deck authority gradient and the failure to detect anomalies in the normal operating behaviour of both the pilots involved.)
  • 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.)
  • B739, Yogyakarta Indonesia, 2015 (On 6 November 2015, a Boeing 737-900 overran the 2,200 metre-long landing runway at Yogyakarta after a tailwind approach with airspeed significantly above the applicable Vref followed by a long landing on a wet runway without optimum use of deceleration devices. The flight crew management of the situation once the aircraft had come to a stop was contrary to procedures in a number of important respects. The aircraft operator took extensive action to improve crew performance following the event. The Investigation found significant fault with the airport operator's awareness of runway surface condition and an absence of related significant risk management.)
  • B743, vicinity Tehran Mehrabad Iran, 2015 (On 15 October 2015 a Boeing 747-300 experienced significant vibration from one of the engines almost immediately after take-off from Tehran Mehrabad. After the climb out was continued without reducing the affected engine thrust an uncontained failure followed 3 minutes later. The ejected debris caused the almost simultaneous failure of the No 4 engine, loss of multiple hydraulic systems and all the fuel from one wing tank. The Investigation attributed the vibration to the Operator's continued use of the engine without relevant Airworthiness Directive action and the subsequent failure to continued operation of the engine after its onset.)
  • AT43, vicinity Oksibil Papua Indonesia, 2015 (On 26 August 2015, contact was lost with an ATR 42-300 making a descent to Oksibil supposedly using detailed Company-provided visual approach guidance over mountainous terrain. Its burnt out wreckage was subsequently located 10 nm from the airport at 4,300 feet aal. The Investigation found that the prescribed guidance had not been followed and that the Captain had been in the habit of disabling the EGPWS to prelude nuisance activations. It was concluded that a number of safety issues identified collectively indicated that the organisational oversight of the aircraft operator by the regulator was ineffective.)
  • 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.)
  • A320, Halifax NS Canada, 2015 (On 29 March 2015, an Airbus A320 crew mismanaged the descent during a night non-precision approach at Halifax and continued below MDA without the mandatory autopilot disconnection until, with inadequate visual reference, the aircraft impacted terrain and obstructions 225 metres short of the runway. The aircraft was destroyed but there were no fatalities. The Investigation found that the crew did not monitor their descent against the required vertical profile, as there was no SOP requiring them to do so, and did not recognise in time that a go around was appropriate.)
  • DH8D, Hubli India, 2015 (On 8 March 2015, directional control of a Bombardier DHC 8-400 which had just completed a normal approach and landing was lost and the aircraft departed the side of the runway following the collapse of both the left main and nose landing gear assemblies. The Investigation found that after being allowed to drift to the side of the runway without corrective action, the previously airworthy aircraft had hit a non-frangible edge light and the left main gear and then the nose landing gear had collapsed with a complete loss of directional control. The aircraft had then exited the side of the runway sustaining further damage.)
  • 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.)
  • A320, en-route Karimata Strait Indonesia, 2014 (On 28 December 2014, an A320 crew took unapproved action in response to a repeating system caution shortly after levelling at FL320. The unexpected consequences degraded the flight control system and obliged manual control. Gross mishandling followed which led to a stall, descent at a high rate and sea surface impact with a 20º pitch attitude and a 50º angle of attack four minutes later. The Investigation noted the accident origin as a repetitive minor system fault but demonstrated that the subsequent loss of control followed a combination of explicitly inappropriate pilot action and the absence of appropriate pilot action.)
  • 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.)
  • B738, Surat India, 2014 (On 6 November 2014, a Boeing 737-800 taking off at night from Surat hit an object as it was approaching 80 knots and the take-off was immediately rejected. On return to the gate substantial damage was found to the left engine and a runway inspection found one dead buffalo and another live one. The runway was reopened after removal of the carcass but the live buffalo was not removed and was seen again by the runway the following day. The Investigation found a history of inadequate perimeter fencing and inadequate runway inspection practices at the airport.)
  • A321, en-route, near Pamplona Spain, 2014 (On 5 November 2014, the crew of an Airbus A321 temporarily lost control of their aircraft in the cruise and were unable to regain it until 4000 feet of altitude had been lost. An investigation into the causes is continuing but it is already known that blockage of more than one AOA probe resulted in unwanted activation of high AOA protection which could not be stopped by normal sidestick inputs until two of the three ADRs had been intentionally deactivated in order to put the flight control system into Alternate Law.)
  • SH36, vicinity Sint Maarten Eastern Caribbean, 2014 (On 29 October 2014, a Shorts SD 3-60 ceased its climb out soon after take-off and was subsequently found to have descended into the sea at increasing speed with the impact destroying the aircraft. The Investigation found that the aircraft had been airworthy prior to the crash and, noting a dark night departure and a significant authority gradient on the fight deck, concluded that the pilot flying had probably experienced a somatogravic illusion as the aircraft accelerated during flap retraction and made a required left turn. The extent of any intervention by the other pilot could not be determined.)
  • 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.)
  • A140, vicinity Tehran Mehrabad Iran, 2014 (On 10 August 2014, one of the engines of an Antonov 140-100 departing Tehran Mehrabad ran down after V1 and prior to rotation. The takeoff was continued but the crew were unable to keep control and the aircraft stalled and crashed into terrain near the airport. The Investigation found that a faulty engine control unit had temporarily malfunctioned and that having taken off with an inappropriate flap setting, the crew had attempted an initial climb with a heavy aircraft without the failed engine propeller initially being feathered, with the gear remaining down and with the airspeed below V2.)
  • AT75, vicinity Magong Taiwan, 2014 (On 23 July 2014, a TransAsia Airways ATR 72-500 crashed into terrain shortly after commencing a go around from a VOR approach at its destination in day IMC in which the aircraft had been flown significantly below the MDA without visual reference. The aircraft was destroyed and48 of the 58 occupants were killed. The Investigation found that the accident was entirely attributable to the actions of the crew and that it had occurred in a context of a systemic absence of effective risk management at the Operator which had not been adequately addressed by the Safety Regulator.)
  • 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.)
  • 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.)
  • 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.)
  • 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.)
  • B744, Johannesburg South Africa, 2013 (On 22 December 2013, a Boeing 747-400 taxiing for departure at Johannesburg at night with an augmented crew failed to follow its correctly-acknowledged taxi clearance and one wing hit a building resulting in substantial damage to both aircraft and building and a significant fuel leak. The aircraft occupants were all uninjured but four people in the building sustained minor injuries. The accident was attributed to crew error both in respect of an inadequate briefing and failure to monitor aircraft position using available charts and visual reference. Some minor contributory factors relating to the provision of airport lighting and signage were noted.)
  • B738, Dubai UAE, 2013 (On 6 December 2013, a Boeing 737-800 passenger aircraft was flown from Amman to Dubai out of revenue service with a quantity of 'live' boxed chemical oxygen generators on board as cargo without the awareness of the aircraft commander. The subsequent Investigation found that this was possible because of a wholesale failure of the aircraft operator to effectively oversee operational risk implicit in sub contracting heavy maintenance. As a result of the investigation, a previously unreported flight by the same operator in revenue service which had also carried live oxygen generators was disclosed.)
  • A320 / B739, Yogyakarta Indonesia, 2013 (On 20 November 2013, an A320 misunderstood its taxi out clearance at Yogyakarta and began to enter the same runway on which a Boeing 737, which had a valid landing clearance but was not on TWR frequency, was about to touch down from an approach in the other direction of use. On seeing the A320, which had stopped with the nose of the aircraft protruding onto the runway, the 737 applied maximum manual braking and stopped just before reaching the A320. The Investigation faulted ATC and airport procedures as well as the A320 crew for contributing to the risk created.)
  • B735, vicinity Kazan Russia, 2013 (On 17 November 2013, the crew of a Boeing 737-500 failed to establish on the ILS at Kazan after not following the promulgated intermediate approach track due to late awareness of LNAV map shift. A go around was eventually initiated from the unstabilised approach but the crew appeared not to recognise that the autopilot used to fly the approach would automatically disconnect. Non-control followed by inappropriate control led to a high speed descent into terrain less than a minute after go around commencement. The Investigation found that the pilots had not received appropriate training for all-engine go arounds or upset recovery.)
  • AT43, Madang Papua New Guinea, 2013 (On 19 October 2013, an ATR42 freighter departing Madang had to reject its takeoff when it was impossible to rotate and it ended up semi-submerged in a shallow creek beyond the airfield perimeter. The Investigation found that loading had been contrary to instructions and the aircraft had a centre of gravity outside the permitted range and was overweight. This was attributed to the aircraft operator’s lack of adequate procedures for acceptance and loading of cargo. A lack of appreciation by all parties of the need to effectively mitigate runway overrun risk in the absence of a RESA was also highlighted.)
  • AT72, vicinity Pakse Laos, 2013 (On 16 October 2013, the crew of an ATR72-600 unintentionally flew their aircraft into the ground in IMC during a go around from an unsuccessful non precision approach at destination Pakse. The Investigation concluded that although the aircraft had followed the prescribed track, the crew had been confused by misleading FD indications resulting from their failure to reset the selected altitude to the prescribed stop altitude so that the decision altitude they had used for the approach remained as the selected altitude. Thereafter, erratic control of aircraft altitude had eventually resulted in controlled flight into terrain killing all on board.)
  • DC3, vicinity Yellowknife Canada, 2013 (On 19 August 2013, a fire occurred in the right engine of a Douglas DC3-C on take off from Yellowknife. After engine shutdown, a right hand circuit was made in an attempt to land back on another runway but trees were struck and the aircraft crash-landed south of it. Emergency evacuation was successful. The Investigation found that a pre-existing cylinder fatigue crack had caused the engine failure/fire and that the propeller feathering pump had malfunctioned. It was found that an overweight take off had occurred and that various unsafe practices had persisted despite the regulatory approval of the Operator's SMS.)
  • B738, Djalaluddin Indonesia, 2013 (On 6 August 2013, a Boeing 737-800 encountered cows ahead on the runway after landing normally in daylight following an uneventful approach and was unable to avoid colliding with them at high speed and as a result departed the runway to the left. Parts of the airport perimeter fencing were found to have been either missing or inadequately maintained for a significant period prior to the accident despite the existence of an airport bird and animal hazard management plan. Corrective action was taken following the accident.)
  • C56X, Port Harcourt Nigeria, 2013 (On 14 July 2011, the crew of a Cessna Citation intentionally continued a night ILS approach at Port Harcourt below the applicable DA without having any visual reference with the runway and a crash landing and lateral runway excursion which severely damaged the aircraft followed. The Investigation did not establish any reason for the violation of minima but noted the complications which had arisen in respect of CRM because of two-Captain flight crew. Absence of two-way radio communications between the fire trucks and both ATC and the AFS Watch Room was noted to have delayed discovery of the crashed aircraft.)
  • B788, London Heathrow UK, 2013 (On 12 July 2013 an unoccupied and unpowered Boeing 787-8, remotely parked at London Heathrow after an arrival earlier the same day caught fire. An investigation found that the source of the fire was an uncontained thermal runaway in the lithium-metal battery within an Emergency Locator Transmitter (ELT). Fifteen Safety Recommendations, all but one to the FAA, were made as a result of the Investigation.)
  • B772, San Francisco CA USA, 2013 (On 6 July 2013, an Asiana Boeing 777-200 descended below the visual glidepath on short finals at San Francisco after the pilots failed to notice that their actions had reduced thrust to idle. Upon late recognition that the aircraft was too low and slow, they were unable to recover before the aircraft hit the sea wall and the tail detached. Control was lost and the fuselage eventually hit the ground. A few occupants were ejected at impact but most managed to evacuate subsequently and before fire took hold. The Probable Cause of the accident was determined to be the mismanagement of the aircraft by the pilots.)
  • SF34, Marsh Harbour Bahamas, 2013 (On 13 June 2013, a rushed and unstable visual approach to Marsh Harbour by a Saab 340B was followed by a mishandled landing and a runway excursion. The Investigation concluded that the way the aircraft had been operated had been contrary to expectations in almost every respect. This had set the scene for the continuation of a visual approach to an attempted landing in circumstances where there had been multiple indications that there was no option but to break off the approach, including a total loss of forward visibility in very heavy rain as the runway neared.)
  • 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.)
  • S76, vicinity Moosonee ON Canada, 2013 (On 31 May 2013 the crew of an S76A helicopter positioning for a HEMS detail took off VFR into a dark night environment and lost control as a low level turn was initiated and did not recover. The helicopter was destroyed and the four occupants killed. The Investigation found that the crew had little relevant experience and were not "operationally ready" to conduct a night VFR take off into an area of total darkness. Significant deficiencies at the Operator and in respect of the effectiveness of its Regulatory oversight were identified as having been a significant context for the accident.)
  • A319, London Heathrow UK, 2013 (On 24 May 2013 the fan cowl doors on both engines of an Airbus A319 detached as it took off from London Heathrow. Their un-latched status after a routine maintenance input had gone undetected. Extensive structural and system damage resulted and a fire which could not be extinguished until the aircraft was back on the ground began in one engine. Many previously-recorded cases of fan cowl door loss were noted but none involving such significant collateral damage. Safety Recommendations were made on aircraft type certification in general, A320-family aircraft modification, maintenance fatigue risk management and aircrew procedures and training.)
  • DHC6, Jomson Nepal, 2013 (On 16 May 2013, a DHC6-300 on a domestic passenger flight made a tailwind touchdown at excessive speed in the opposite direction of the of 740 metre-long runway to the notified direction in use and, after departing the runway to one side during deceleration, re-entered the runway and attempted to take off. This failed and the aircraft breached the perimeter fence and fell into a river. The Investigation identified inappropriate actions of the aircraft commander in respect of both the initial landing and his response to the subsequent runway excursion and also cited the absence of effective CRM.)
  • B738, vicinity Denpasar Bali Indonesia, 2013 (On 13 April 2013, a Lion Air Boeing 737-800 flew a day non precision approach to runway 09 at Bali (Denpasar) and continued when the required visual reference was lost below MDA. Despite continued absence of visual reference, the approach was continued until the EGPWS annunciation 'TWENTY', when the aircraft commander called a go around. Almost immediately, the aircraft hit the sea surface to the right of the undershoot area and broke up. All 108 occupants were rescued with only four sustaining serious injury. The Investigation attributed the accident entirely to the actions and inactions of the two pilots.)
  • B788, Boston MA USA, 2013 (On 7 January 2013, a battery fire on a Japan Air Lines Boeing 787-8 began almost immediately after passengers and crew had left the aircraft after its arrival at Boston on a scheduled passenger flight from Tokyo Narita. The primary structure of the aircraft was undamaged. Investigation found that an internal short circuit within a cell of the APU lithium-ion battery had led to uncontained thermal runaway in the battery leading to the release of smoke and fire. The origin of the malfunction was attributed to system design deficiency and the failure of the type certification process to detect this.)
  • SW4, Sanikiluaq Nunavut Canada, 2012 (On 22 December 2012, the crew of a Swearingen SA227 attempting a landing, following an unstabilised non-precision approach at Sanikiluaq at night with questionable alternate availability in marginal weather conditions, ignored GPWS PULL UP Warnings, then failed in their attempt to transition into a low go around and the aircraft crashed into terrain beyond the runway. One occupant – an unrestrained infant – was killed and the aircraft was destroyed. The Investigation faulted crew performance, the operator and the regulator and reiterated that lap-held infants were vulnerable in crash impacts.)
  • DH8C, vicinity Abu Dhabi UAE, 2012 (On 9 September 2012, the crew of a DHC8-300 climbing out of Abu Dhabi declared a PAN and returned after visual evidence of the right engine overheating were seen from the passenger cabin. The Investigation found that the observed signs of engine distress were due to hot gas exiting through the cavity left by non-replacement of one of the two sets of igniters on the engine after a pressure wash carried out overnight prior to the flight and that the left engine was similarly affected. The context for the error was identified as a dysfunctional maintenance organisation at the Operator.)
  • C500, vicinity Santiago Spain, 2012 (On 2 August 2012, a Cessna 500 positioning back to base after completing an emergency medical team transfer operation earlier in the night crashed one mile short of the runway at Santiago in landing configuration after being cleared to make an ILS approach. The Investigation concluded that the approach was unstabilised, had been flown without following the ILS GS and that the crew had used DME distance from the VOR near the crash position rather than the ILS DME. Fog was present in and around the airport.)
  • MD83, vicinity Lagos Nigeria, 2012 (On 3 June 2012, the crew of a Boeing MD-83 experienced problems in controlling the thrust from first one engine and then also the other which dramatically reduced the amount of thrust available. Eventually, when a few miles from destination Lagos, it became apparent that it would be impossible to reach the runway and the aircraft crashed in a residential district killing all 153 occupants and 6 people on the ground. The Investigation was unable to conclusively identify the cause of the engine malfunctions but attributed the accident outcome to the crew's failure to make a timely diversion to an alternative airport.)
  • SU95, manoeuvring near Jakarta Indonesia, 2012 (On 9 May 2012, a Sukhoi RRJ-95 on a manufacturer-operated demonstration flight out of Jakarta Halim descended below the promulgated safe altitude and, after TAWS alerts and warnings had been ignored, impacted terrain in level flight which resulted in the destruction of the aeroplane and death of all 45 occupants. The Investigation concluded that that the operating crew were unaware that their descent would take them below some of the terrain in the area until the alerts started and then assumed they had been triggered by an incorrect database and switched the equipment off.)
  • S76, Peasmarsh East Sussex UK, 2012 (On 3 May 2012, a Sikorsky S76C operating a passenger flight to a private landing site at night discontinued an initial approach because of lack of visual reference in an unlit environment and began to position for another. The commander became spatially disorientated and despite a number of EGPWS Warnings, continued manoeuvring until ground impact was only narrowly avoided - the minimum recorded height was 2 feet +/- 2 feet. An uneventful diversion followed. The Investigation recommended a review of the regulations that allowed descent below MSA for landing when flying in IMC but not on a published approach procedure.)
  • 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.)
  • A320, vicinity Lyons Saint-Exupéry France, 2012 (On 11 April 2012, a Hermes Airlines A320 commanded by a Training Captain who was also in charge of Air Operations for the airline was supervising a trainee Captain on a night passenger flight. The aircraft failed to establish on the Lyons ILS and, in IMC, descended sufficiently to activate both MSAW and EGPWS 'PULL UP' warnings which eventually prompted recovery. The Investigation concluded that application of both normal and emergency procedures had been inadequate and had led to highly degraded situational awareness for both pilots. The context for this was assessed as poor operational management at the airline.)
  • AT72, vicinity Tyumen Russian Federation, 2012 (On 2 April 2012, the crew of an ATR72-200 which had just taken off from Tyumen lost control of their aircraft when it stalled after the flaps were retracted and did not recover before it crashed and caught fire killing or seriously injuring all occupants. The Investigation found that the Captain knew that frozen deposits had accumulated on the airframe but appeared to have been unaware of the danger of not having the airframe de-iced. It was also found that the crew had not recognised the stall when it occurred and had overpowered the stick pusher and pitched up.)
  • 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.)
  • CRJ1, Kinshasa Democratic Republic of Congo, 2011 (On 4 April 2011, the crew of a Georgian Airways Bombardier CRJ100 operating a domestic flight for the United Nations lost control of their aircraft as they commenced a go around from below the MDA for the non precision approach flown due to an absence of visual reference with the runway. They were aware from their weather radar of severe convective weather in the vicinity of the airport although the METAR passed by ATC did not indicate this. The aircraft crashed alongside the runway and was destroyed. All occupants except one who was seriously injured were killed.)
  • 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.)
  • SW4, Cork Ireland, 2011 (On 10 February 2011, control of a Spanish-operated Fairchild SA227 operating a scheduled passenger flight from Belfast UK to Cork, Ireland was lost during an attempt to commence a third go around due to fog from 100 feet below the approach minimum height. The Investigation identified contributory causes including serial non-compliance with many operational procedures and inadequate regulatory oversight of the Operator. Complex relationships were found to prevail between the Operator and other parties, including “Manx2”, an Isle of Man-based Ticket Seller under whose visible identity the aircraft operated. Most resultant Safety Recommendations concerned systemic improvement in regulatory oversight effectiveness.)
  • TBM8, Birmingham UK, 2011 (On 12 January 2011, a privately operated Socata TBM850 light aircraft on a flight from Antwerp to Birmingham lost radio contact with ATC whilst in IMC on a non precision approach to runway 15 prior to the issue of a landing clearance and prior to checking in on the ATC TWR frequency. It continued the approach to obtain the required visual reference before landing over the top of a DHC8-400 aircraft which had lined up ready for take off in accordance with ATC instructions. No damage or personal injury resulted from the close proximity.)
  • A306, East Midlands UK, 2011 (On 10 January 2011, an Air Atlanta Icelandic Airbus A300-600 on a scheduled cargo flight made a bounced touchdown at East Midlands and then attempted a go around involving retraction of the thrust reversers after selection out and before they had fully deployed. This prevented one engine from spooling up and, after a tail strike during rotation, the single engine go around was conducted with considerable difficulty at a climb rate only acceptable because of a lack of terrain challenges along the climb out track.)
  • 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.)
  • 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.)
  • A332/A345, Khartoum Sudan, 2010 (On 30 September 2010, an A330-200 was about to take off from Khartoum at night in accordance with its clearance when signalling from a hand-held flashlight and a radio call from another aircraft led to this not taking place. The other (on-stand) aircraft crew had found that they had been hit by the A330 as it had taxied past en route to the runway. The Investigation found that although there was local awareness that taxiway use and the provision of surface markings at Khartoum did not ensure safe clearance between aircraft, this was not being communicated by NOTAM or ATIS.)
  • DC86, Manston UK, 2010 (On 11 August 2010, a Douglas DC8-63F being operated by Afghanistan-based operator Kam Air on a non scheduled cargo flight from Manston UK to Sal, Cape Verde Islands failed to get airborne until after the end of departure runway 28 during a daylight take off in normal visibility. The aircraft eventually became airborne and climbed away normally and when ATC advised of the tail strike, the aircraft commander elected to continue the flight as planned and this was achieved without further event. Minor damage to the aircraft was found after flight and there was also damage to an approach light for the reciprocal runway direction.)
  • A139, vicinity Sky Shuttle Heliport Hong Kong China, 2010 (On 3 July 2010, an AW 139 helicopter was climbing through 350 feet over water two minutes after take off when the tail rotor fell off. A transition to autorotation was accomplished and a controlled ditching followed. All on board were rescued, some sustained minor injuries. The failure was attributed entirely to manufacturing defects but no action was taken until two similar accidents had occurred in Qatar (non-fatal) and Brazil (fatal) the following year and two Safety Recommendations had been issued from this Investigation after which a comprehensive review of the manufacturing process resulted in numerous changes monitored by EASA.)
  • B738, Mangalore India, 2010 (On 22 May 2010, an Air India Express Boeing 737-800 overran the landing runway at Mangalore when attempting a go around after thrust reverser deployment following a fast and late touchdown off an unstable approach. Almost all of the 166 occupants were killed when control was lost and the aircraft crashed into a ravine off the end of the runway. It was noted a relevant factor in respect of the approach, landing and failed go around attempt was probably the effect of ‘sleep inertia’ on the Captain’s performance and judgement after a prolonged sleep en-route)
  • A333, Hong Kong China, 2010 (On 13 April 2010, a Cathay Pacific Airbus A330-300 en route from Surabaya to Hong Kong experienced difficulty in controlling engine thrust. As these problems worsened, one engine became unusable and a PAN and then a MAYDAY were declared prior to a successful landing at destination with excessive speed after control of thrust from the remaining engine became impossible. Emergency evacuation followed after reports of a landing gear fire. Salt water contamination of the hydrant fuel system at Surabaya after alterations during airport construction work was found to have led to the appearance of a polymer contaminant in uplifted fuel.)
  • T154, vicinity Smolensk Russian Federation, 2010 (On 10 April 2010, a Polish Air Force Tupolev Tu-154M on a pre-arranged VIP flight into Smolensk Severny failed to adhere to landing minima during a non precision approach with thick fog reported and after ignoring a TAWS ‘PULL UP’ Warning in IMC continued descent off track and into the ground. All of the Contributory Factors to the pilot error cause found by the Investigation related to the operation of the aircraft in a range of respects including a failure by the crew to obtain adequate weather information for the intended destination prior to and during the flight.)
  • B738, Kingston Jamaica, 2009 (On 22 December 2009, the flight crew of an American Airlines’ Boeing 737-800 made a long landing at Kingston at night in heavy rain and with a significant tailwind component and their aircraft overran the end of the runway at speed and was destroyed beyond repair. There was no post-crash fire and no fatalities, but serious injuries were sustained by 14 of the 154 occupants. The accident was attributed almost entirely to various actions and inactions of the crew. Damage to the aircraft after the overrun was exacerbated by the absence of a RESA.)
  • E135, George South Africa, 2009 (On 7 December 2009, an South African Airlink Embraer 135 overran the recently refurbished wet landing runway at George after braking was ineffective and exited the aerodrome perimeter to end up on a public road. There was no fire and all occupants were able to evacuate the aircraft. The subsequent investigation attributed the overrun principally to inadequate wet runway friction following the surface maintenance activities and noted various significant non-compliances with ICAO Annex 14.)
  • WW24, vicinity Norfolk Island South Pacific, 2009 (On 18 November 2009, an IAI Westwind on a medevac mission failed to make a planned night landing at Norfolk Island in unanticipated adverse weather and was intentionally ditched offshore because of insufficient fuel to reach the nearest alternate. The fuselage broke in two on water contact but all six occupants escaped from the rapidly sinking wreckage and were eventually rescued. The Investigation initially completed in 2012 was reopened after concerns about its conduct and a new Final Report in 2017 confirmed that the direct cause was flawed crew decision-making but also highlighted ineffective regulatory oversight and inadequate Operator procedures.)
  • AT72, Mumbai India, 2009 (On 10 November 2010, a Kingfisher Airlines ATR 72-200 made an excessively steep and unstabilised tailwind approach in light rain to runway 27 at Mumbai in visual daylight conditions. After touching down late, the aircraft was steered off the side of the runway when it became obvious that an overrun would otherwise occur. The Investigation found that ATC had failed to advise of water patches on the runway and aquaplaning had occurred. It also found that without aquaplaning, the available distance from the actual touchdown point would have been sufficient to stop the aircraft in.)
  • BN2A, vicinity Bonaire Netherlands Antilles, 2009 (On 22 October 2009, a BN2 Islander suspected to have been overloaded experienced an engine failure shortly after departure from Curaçao. Rather than return, the Pilot chose to continue the flight to the intended destination but had to carry out a ditching when it proved impossible to maintain height. All passengers survived but the Pilot died. The cause of the engine failure could not be established but the Investigation found a context for the accident which had constituted systemic failure by the Operator to deliver operational safety which had been ignored by an inadequate regulatory oversight regime.)
  • P28A / S76, Humberside UK 2009 (On 26 September 2009, a Piper PA28-140 flown by an experienced pilot was about to touch down after a day VMC approach about a mile behind an S76 helicopter which was also categorised as 'Light' for Wake Vortex purposes rolled uncontrollably to the right in the flare and struck the ground inverted seriously injuring the pilot. The Investigation noted existing informal National Regulatory Authority guidance material already suggested that light aircraft pilots might treat 'Light' helicopters as one category higher when on approach and recommended that this advice be more widely promulgated.)
  • B772, St Kitts West Indies, 2009 (On 26 September 2009, the crew of a British Airways Boeing 777-200 unintentionally began and completed their take off in good daylight visibility from the wrong intermediate runway position with less than the required take off distance available. Due to the abnormally low weight of the aircraft compared to almost all other departures by this fleet, the aircraft nevertheless became airborne just before the end if the runway. The investigation attributed the error to a poorly marked taxiway and the failure of the crew to include the expected taxi routing in their pre flight briefing.)
  • A332, en-route, Atlantic Ocean, 2009 (On 1 June 2009, an Airbus A330-200 being operated by Air France on a scheduled passenger flight from Rio de Janeiro to Paris CDG as AF447 exited controlled flight and crashed into the sea with the loss of the aircraft and all 228 occupants. It was found that the loss of control followed an inappropriate response by the flight crew to a transient loss of airspeed indications in the cruise which resulted from the vulnerability of the pitot heads to ice crystal icing.)
  • B752, Las Vegas NV USA, 2008 (On 22 December 2008, a Boeing 757-200 on a scheduled passenger flight departing Las Vegas for New York JFK experienced sudden failure of the right engine as take off thrust was set and the aircraft was stopped on the runway for fire services inspection. Fire service personnel observed a hole in the bottom of the right engine nacelle and saw a glow inside so they discharged a fire bottle into the nacelle through the open pressure relief doors. In the absence of any contrary indications, this action was considered to have extinguished any fire and the aircraft was then taxied back to the gate on the remaining serviceable engine for passenger disembarkation. None of the 263 occupants were injured but the affected engine suffered significant damage.)
  • A320, vicinity Perpignan France, 2008 (On 27 November 2008, the crew of an XL Airways A320 on an airworthiness function flight following aircraft repainting lost control of the aircraft after fail to take the action necessary to recover from a full stall which had resulted from their continued airspeed reduction during a low speed handling test when Stall Protection System (SPS) activation did nor occur at the likely airspeed because two of the three angle of attack sensors were blocked by ice formed by water ingress during preparation for the repainting. This condition rendered angle of attack protection in normal law inoperative.)
  • 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.)
  • MD82, Madrid Barajas Spain, 2008 (On 20 August 2008, an MD82 aircraft operated by Spanair took off from Madrid Barajas Airport with flaps and slats retracted; the incorrect configuration resulted in loss of control, collision with the ground, and the destruction of the aircraft.)
  • C500, vicinity Wiley Post Airport, Oklahoma City OK USA, 2008 (On 4 August 2008, a Cessna 500 on a business charter flight encountered a flock of very large birds shortly after take off from a small Oklahoma City airport. Wing damage from at least one bird collision with a force significantly greater than covered by the applicable certification requirements made it impossible for the pilot to retain control of the aircraft. Terrain impact followed. Both engines also ingested a bird. The Investigation noted that neither pilot nor aircraft operator were approved to operate commercial charter flights but concluded that this was not directly connected to the loss of the aircraft.)
  • 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.)
  • B744, en-route NNW of Bangkok Thailand, 2008 (On 7 January 2008, a Boeing 747-400 being operated by Qantas on a scheduled passenger flight from London Heathrow to Bangkok was descending through FL100 about 13.5 nm NNW of destination in day VMC when indications of progressive electrical systems failure began to be annunciated. As the aircraft neared the end of the radar downwind leg, only the AC4 bus bar was providing AC power and the aircraft main battery was indicating discharge. A manual approach to a normal landing was subsequently accomplished and the aircraft taxied to the designated gate where passenger disembarkation took place. None of the 365 occupants, who included two heavy crew members who were present in the flight deck throughout the incident, had sustained any injury and the aircraft was undamaged.)
  • A318/B739, vicinity Amsterdam Netherlands, 2007 (On 6 December 2007 an Airbus A318 being operated by Air France on a scheduled passenger flight from Lyon to Amsterdam carried out missed approach from runway 18C at destination and lost separation in night VMC against a Boeing 737-900 being operated by KLM on a scheduled passenger flight from Amsterdam to London Heathrow which had just departed from runway 24. The conflict was resolved by correct responses to the respective coordinated TCAS RAs after which the A318 passed close behind the 737. There were no abrupt manoeuvres and none of the 104 and 195 occupants respectively on board were injured.)
  • MD83, Are/Ostersund Sweden, 2007 (On 9 September 2007, an MD83 being operated by Austrian Company MAP Jet, which was over the permitted weight for the runway and conditions, made a night take off from Are/Ostersund airport, Sweden, very near the end of the runway and collided with the approach lights for the opposite runway before climbing away.)
  • B773, Auckland Airport New Zealand, 2007 (On 22 March 2007, an Emirates Boeing 777-300ER, started its take-off on runway 05 Right at Auckland International Airport bound for Sydney. The pilots misunderstood that the runway length had been reduced during a period of runway works and started their take-off with less engine thrust and flap than were required. During the take-off they saw work vehicles in the distance on the runway and, realising something was amiss, immediately applied full engine thrust and got airborne within the available runway length and cleared the work vehicles by about 28 metres.)
  • B734, en-route, Sulawesi Indonesia, 2007 (On 1 January 2007, a B737-400 crashed into the sea off Sulawesi, Indonesia, after the crew lost control of the aircraft having become distracted by a minor technical problem.)
  • AT45, vicinity Sienajoki Finland, 2007 (On 1 January 2007, the crew of a ATR 42-500 carried out successive night approaches into Seinajoki Finland including three with EGPWS warnings, one near stall, and one near loss of control, all attributed to poor flight crew performance including use of the wrong barometric sub scale setting.)
  • B738 / E135, en-route, Mato Grosso Brazil, 2006 (On 29 September 2006, a Boeing 737-800 level at FL370 collided with an opposite direction Embraer Legacy at the same level. Control of the 737 was lost and it crashed, killing all 154 occupants. The Legacy's crew kept control and successfully diverted to the nearest suitable airport. The Investigation found that ATC had not instructed the Legacy to descend to FL360 when the flight plan indicated this and soon afterwards, its crew had inadvertently switched off their transponder. After the consequent disappearance of altitude from all radar displays, ATC assumed but did not confirm the aircraft had descended.)
  • 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.)
  • CRJ1, Lexington KY USA, 2006 (On 27 August 2006, a Bombardier CRJ100 cleared for a night take off from runway 22 instead began take off on unlit runway 26. It was too short and the aircraft ran off the end at speed and was destroyed by the subsequent impact and post-crash fire with the deaths of 49 of the 50 occupants - the First Officer surviving with serious injuries. The Investigation found that the actions of the flight crew had caused the accident but noted that insufficiently robust ATC procedures had been contributory and the effects of an ongoing runway extension project had been relevant.)
  • A310, Irkutsk Russia, 2006 (On 8 July 2006, S7 Airlines A310 overran the runway on landing at Irkutsk at high speed and was destroyed after the Captain mismanaged the thrust levers whilst attempting to apply reverse only on one engine because the flight was being conducted with one reverser inoperative. The Investigation noted that the aircraft had been despatched on the accident flight with the left engine thrust reverser de-activated as permitted under the MEL but also that the previous two flights had been carried out with a deactivated right engine thrust reverser.)
  • DC87, Philadelphia USA, 2006 (On 7 February 2006, towards the end of a flight to Philadelphia, the crew of a DC8-71F detected possible signs of a fire and eventually a system warning confirming that a fire may be developing in part of the main deck cargo. During the subsequent landing, thick black smoke entered the flight deck and an emergency evacuation was performed immediately after the aircraft stopped. Despite the efforts of the emergency services, the aircraft was subsequently destroyed by fire which the Investigation traced to containers which it was suspected but not proved had been loaded with goods which included lithium batteries.)
  • B737, Chicago Midway USA, 2005 (On 8 December 2005, a delay in deploying the thrust reversers after a Boeing 737-700 touchdown at night on the slippery surface of the 1176 metre-long runway at Chicago Midway with a significant tailwind component led to it running off the end, subsequently departing the airport perimeter and hitting a car before coming to a stop. The Investigation concluded that pilots’ lack of familiarity with the autobrake system on the new 737 variant had distracted them from promptly deploying the reversers and that inadequate pilot training provision and the ATC failure to provide adequate braking action information had contributed.)
  • D328, Isle of Man, 2005 (On 28 November 2005, a Dornier 328 departing from Isle of Man was unable to rotate at the speed calculated as applicable but the crew were able to complete a successful rejected take off. The Investigation found that the crew had failed to use the increased tale off speeds which were required for the aircraft type involved after the aircraft had been de/anti iced prior to taxiing for takeoff.)
  • AS50, en-route, Hawaii USA, 2005 (On 23 September 2005, an AS350 helicopter, operated by Heli USA Airways, crashed into the sea off Hawaii following loss of control associated with flight into adverse weather conditions.)
  • AT43, en-route, Folgefonna Norway, 2005 (On 14 September 2005, an ATR 42-320 operated by Coast Air AS experienced a continuous build up of ice in the climb, despite the activation of de-icing systems aircraft entered an uncontrolled roll and lost 1500ft in altitude. The crew initiated recovery actions, the aircraft was stabilised, and the flight continued without further event.)
  • MD82, en-route, near Machiques Venezuela, 2005 (On 16 August 2005, the flight crew of a West Caribbean MD82 on a passenger flight from Tocumen Airport in Panama to Martinique attempted to cruise at a level which was incompatible with aircraft performance. They then failed to recognise the results of this action and when the lack of sufficient engine thrust led to an aerodynamic stall and confusion precluded a recovery before the aircraft impacted terrain at high speed out of control killing all 152 occupants.)
  • 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.)
  • 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.)
  • CL60, Teterboro USA, 2005 (On 2 February 2005, a Challenger, belonging to Platinum Jet Management, crashed after taking off from Teterboro, New Jersey, USA. The aircraft's center of gravity was well forward of the forward takeoff limit.)
  • A320, Harstad/Narvik Norway 2004 (On 25 November 2004, a MyTravel Airways Airbus A320 departed the side of the runway at Harstad, Norway at a low speed after loss of directional control when thrust was applied for a night take off on a runway with below normal surface friction characteristics. It was found that the crew had failed to follow an SOP designed to ensure that any accumulated fan ice was shed prior to take off and also failed to apply take off thrust as prescribed, thus delaying their appreciation of the uneven thrust produced.)
  • C550, vicinity Cagliari Sardinia Italy, 2004 (On 24 February 2004, a Cessna 550 inbound to Cagliari at night requested and was approved for a visual approach without crew awareness of the surrounding terrain. It was subsequently destroyed by terrain impact and a resultant fire during descent and all occupants were killed. The Investigation concluded that the accident was the consequence of the way the crew conducted the flight in the absence of adequate visual references and with the possibility of a ‘black hole’ effect. It was also noted that the aircraft was not fitted, nor required to be fitted, with TAWS.)
  • DH8A, Ottawa Canada, 2003 (On 04 November 2003, the crew of a de Havilland DHC-8-100 which had been de/anti iced detected a pitch control restriction as rotation was attempted during take off from Ottawa and successfully rejected the take off from above V1. The Investigation concluded that the restriction was likely to have been the result of a remnant of clear ice migrating into the gap between one of the elevators and its shroud when the elevator was moved trailing edge up during control checks and observed that detection of such clear ice remnants on a critical surface wet with de-icing fluid was difficult.)
  • B738, Manchester UK, 2003 (On 16 July 2003, a Boeing 737-800, being operated by Excel Airlines on a passenger flight from Manchester to Kos began take off on Runway 06L without the flight crew being aware of work in progress at far end of the runway. The take off calculations, based on the full runway length resulted in the aircraft passing within 56 ft of a 14 ft high vehicle just after take off.)
  • MD88, Groningen Netherlands, 2003 (On 17 June 2003, a crew of a Boeing MD-88, belonging to Onur Air, executed a high speed rejected take-off at a late stage which resulted in overrun of the runway and serious damage to the aircraft.)
  • T154 / B752, en-route, Uberlingen Germany, 2002 (On 1st July 2002, a Russian-operated Tu154 on a passenger flight collided at night with a cargo Boeing 757-200 over Überlingen, Germany with the consequent loss of control of both aircraft and the death of all occupants. The collision occurred after an ATC control lapse had led to a conflict which generated coordinated TCAS RAs which the B757 followed but the TU-154, in the presence of a conflicting ATC instruction, did not.)
  • MD87 / C525, Milan Linate, 2001 (On 8th October 2001, an SAS MD-87 taking off as cleared from Milan Linate in thick fog collided at high speed with a German-operated Cessna Citation which had failed to follow its taxi clearance and unknown to ATC had eventually crossed a lit red stop bar and entered the active runway just as the MD-87 was reaching the same point. After the collision, the MD-87 continued along the ground until it impacted, still at high speed, a ground handling building. Both aircraft caught fire and were destroyed. The 114 occupants of both aircraft and 4 ground personnel were killed.)
  • SH36, vicinity Edinburgh UK, 2001 (On 27 February 2001, a Loganair SD3-60 lost all power on both engines soon after take off from Edinburgh. An attempt to ditch in the Firth or Forth in rough seas resulted in the break up and sinking of the aircraft and neither pilot survived. The loss of power was attributed to the release of previously accumulated frozen deposits into the engine core when the engine anti icing systems were selected on whilst climbing through 2200 feet. These frozen deposits were considered to have accumulated whilst the aircraft had been parked prior to flight without engine intake blanks fitted.)
  • A320, Bilbao Spain, 2001 (On 7th February 2001, an Iberia A320 was about to make a night touch down at Bilbao in light winds when it experienced unexpected windshear. The attempt to counter the effect of this by initiation of a go around failed because the automatic activation of AOA protection in accordance with design criteria which opposed the crew pitch input. The aircraft then hit the runway so hard that a go around was no longer possible. Severe airframe structural damage and evacuation injuries to some of the occupants followed. A mandatory modification to the software involved was subsequently introduced.)
  • B744, Taipei Taiwan, 2000 (On 31 October 2000, the crew of a Singapore Airlines Boeing 747-400 taxiing for a night departure at Taipei in reduced (but not 'low') visibility with an augmenting crew member present on the flight deck failed to follow their correctly-confirmed taxi instructions and commenced take off on a partially closed runway. The subsequent collision with construction equipment and resultant severe post crash fire destroyed the aircraft killing over half the 170 occupants and injured 71 others. All three flight crew survived.)
  • CONC, vicinity Paris Charles de Gaulle France, 2000 (On 25th July 2000, an Air France Concorde crashed shortly after take-off from Paris CDG following loss of control after debris from an explosive tyre failure between V1 and VR attributed to runway FOD ruptured a fuel tank and led to a fuel-fed fire which quickly resulted in loss of engine thrust and structural damage which made the aircraft impossible to fly. It was found that nothing the crew failed to do, including rejecting the take off after V1 could have prevented the loss of the aircraft and that they had been faced with entirely unforeseen circumstances.)
  • MD83, en-route, Pacific Ocean near Anacapa Island CA USA, 2000 (On 31 January 2000, an Alaskan Airlines MD83, crashed into the sea off the coast of California, USA, following loss of control attributed to failure of the horizontal stabiliser trim system.)
  • 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.)
  • 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.)
  • DC86, en-route, Narrows VA USA, 1996 (On 22 December 1996, during a post-maintenance airworthiness function flight at night in IMC, a Douglas DC8 operated by Airborne Express failed to recover from an intentional approach to the stall and loss of control without recovery followed leading to impact into mountainous terrain in the vicinity of Narrows, Virginia.)
  • 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.)
  • DC93, en-route, north west of Miami USA, 1996 (On 11 May 1996, the crew of a ValuJet DC9-30 were unable to keep control of their aircraft after fire broke out. The origin of the fire was found to have been live chemical oxygen generators loaded contrary to regulations. The Investigation concluded that, whilst the root cause was poor practices at SabreTech (the maintenance contractor which handed over oxygen generators in an unsafe condition), the context for this was oversight failure at successive levels - Valujet over SabreTech and the FAA over Valujet. Failure of the FAA to require fire suppression in Class 'D' cargo holds was also cited.)
  • 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.)
  • AT73, en-route, Roselawn IN USA, 1994 (On 31 October 1994, an ATR 72 exited controlled flight after a flap retraction when descending through 9000 feet was followed by autopilot disconnect and rapid and very large un-commanded roll inputs from which recovery, not within the scope of received crew training, was not achieved. The investigation found this roll upset had been due to a sudden and unexpected aileron hinge moment reversal after ice accretion on the upper wings aft of the leading edge pneumatic de-icing boots during earlier holding in icing conditions which had been - unknown to the crew - outside the icing certification envelope.)
  • B763, en-route, North West Thailand, 1991 (On 26 May 1991, a Lauda Air Boeing 767-300 experienced an un-commanded deployment of a thrust reverser climbing out of Bangkok which quickly led to a terminal loss of control and subsequent ground impact which destroyed the aircraft. The cause of the PW4000 thrust reverser fault was not established but it was noted that certification requirements included the ability to continue flight under any possible thrust reverser position and that there had been no pilot training requirement for, or awareness of, the essential response which would have required full aileron and rudder corrective action within 4 to 6 seconds.)
  • 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.)
  • DC91 / B722, Detroit MI USA, 1990 (On 3 December 1990 a Douglas DC9-10 flight crew taxiing for departure at Detroit in thick fog got lost and ended up stopped to one side of an active runway where, shortly after reporting their position, their aircraft was hit by a departing Boeing 727-200 and destroyed by the impact and subsequent fire. The Investigation concluded that the DC9 crew had failed to communicate positional uncertainty quickly enough but that their difficulties had been compounded by deficiencies in both the standard of air traffic service and airport surface markings, signage and lighting undetected by safety regulator oversight.)
  • 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.)
  • 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, 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, 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.)
  • DC10, en-route, Paris France, 1974 (On 3 March 1974, all 346 occupants were killed when a Turkish Airlines McDonnell Douglas DC 10 suffered an explosive decompression after an improperly secured hold door detached passing 12000ft in the climb shortly after departing Paris Orly. It was found that non-mandated corrective actions promulgated after the investigation into a similar DC10 explosive decompression in Canada nearly two years earlier had identified an identical fault in the door closure mechanism which had allowed it to indicate and appear secured when it was not had not been completed on the aircraft at the time of the accident.)

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