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  • B732, Pekanbaru Indonesia, 2002 (Synopsis: On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.)
  • B732, vicinity Washington National DC USA, 1982 (Synopsis: On 13 January 1982, an Air Florida Boeing 737-200 took off in daylight from runway 36 at Washington National in moderate snow but then stalled before hitting a bridge and vehicles and continuing into the river below after just one minute of flight killing most of the occupants and some people on the ground. The accident was attributed entirely to a combination of the actions and inactions of the crew in relation to the prevailing adverse weather conditions and, crucially, to the failure to select engine anti ice on which led to over reading of actual engine thrust.)
  • B733, Tabing Padang Indonesia, 2012 (Synopsis: On 13 October 2012, the crew of a Boeing 737-300 destined for the new Padang airport at Minangkabau inadvertently landed their aircraft on runway 34 at the old Padang Airport at Tabing which has a similarly-aligned runway. The Investigation found that the Captain disregarded ILS indications for the correct approach after visually acquiring the similarly aligned runway when the correct runway was not also in sight. Since the chosen runway was some 6 miles ahead of the intended one, a high descent rate achieved through sideslip, followed with this unstable approach, continued to an otherwise uneventful landing.)
  • B733, vicinity Belfast Aldergrove UK, 2006 (Synopsis: On 18 July 2006, a Boeing 737-300 being operated by a Spanish Airline commenced a daylight non precision approach with a 12 degree offset FAT towards Belfast Aldergrove but then made an unstable descent to 200 feet agl towards an unlicensed runway at a different airport before being told by ATC radar to go around. A further also unstable approach to the correct airport/runway followed. The Investigation noted that there were multiple cues indicating that an approach to the wrong airport was being made and was not able to establish any reason why two successive unstable approaches were not discontinued)
  • B734, Lahore Pakistan, 2015 (Synopsis: On 3 November 2015, a Boeing 737-400 continued an unstabilised day approach to Lahore. When only the First Officer could see the runway at MDA, he took over from the Captain but the Captain took it back when subsequently sighting it. Finally, the First Officer took over again and landed after recognising that the aircraft was inappropriately positioned. Both main gear assemblies collapsed as the aircraft veered off the runway. The Investigation attributed the first collapse to the likely effect of excessive shimmy damper play and the second collapse to the effects of the first aggravated by leaving the runway.)
  • B734, Yogyakarta Indonesia, 2007 (Synopsis: On 7 March 2007, a Boeing 737-400 being operated by Garuda landed on a scheduled passenger flight from Jakarta to Yogyakarta overran the end of the destination runway at speed in normal daylight visibility after a late and high speed landing attempt ending up 252 metres beyond the end of the runway surface in a rice paddy field. There was a severe and prolonged fire which destroyed the aircraft (see the illustration below taken from the Investigation Report) and 21 of the 140 occupants were killed, 12 seriously injured, 100 suffered minor injuries and 7 were uninjured.)
  • B734, en-route, Daventry UK, 1995 (Synopsis: 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.)
  • B735, vicinity Perm Russian Federation, 2008 (Synopsis: On September 13 2008, at night and in good visual conditions*, a Boeing 737-500 operated by Aeroflot-Nord executed an unstabilised approach to Runway 21 at Bolshoye Savino Airport (Perm) which subsequently resulted in loss of control and terrain impact.)
  • B737 / B737, vicinity Geneva Switzerland, 2006 (Synopsis: On 11 May 2006, B737-700 taking off from Geneva came into close proximity with a Boeing Business Jet (BBJ) on a non revenue positioning flight which had commenced a go around from the same runway following an unstabilised approach. The Investigation attributed the conflict to the decision of ATC to give take off clearance to the departing aircraft when the approach of the inbound aircraft could have been seen as highly likely to result is a go around which would lead to proximity with the slower departing aircraft.)
  • B737 en-route, Glen Innes NSW Australia, 2007 (Synopsis: On 17 November 2007 a Boeing 737-700 made an emergency descent after the air conditioning and pressurisation system failed in the climb out of Coolangatta at FL318 due to loss of all bleed air. A diversion to Brisbane followed. The Investigation found that the first bleed supply had failed at low speed on take off but that continued take off had been continued contrary to SOP. It was also found that the actions taken by the crew in response to the fault after completing the take off had also been also contrary to those prescribed.)
  • B737, Chicago Midway USA, 2005 (Synopsis: 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.)
  • B737, manoeuvring, west of Norwich UK 2009 (Synopsis: On 12 January 2009, the flight crew of an Easyjet Boeing 737-700 on an airworthiness function flight out of Southend lost control of the aircraft during a planned system test. Controlled flight was only regained after an altitude loss of over 9000 ft, during which various exceedences of the AFM Flight Envelope occurred. The subsequent investigation found that the Aircraft Operators procedures for such flights were systemically flawed.)
  • B738, Belfast International UK, 2017 (Synopsis: On 21 July 2017, a Boeing 737-800 taking off from Belfast was only airborne near the runway end of the runway and then only climbed at a very shallow angle until additional thrust was eventually added. The Investigation found that the thrust set had been based on an incorrectly input surface temperature of -52°C, the expected top of climb temperature, instead of the actual surface temperature. Although inadequate acceleration had been detected before V1, the crew did not intervene. It was noted that neither the installed FMC software nor the EFBs in use were conducive to detection of the data input error.)
  • B738, Dubai UAE, 2013 (Synopsis: 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.)
  • B738, Katowice Poland, 2007 (Synopsis: On 28 October 2007, a Boeing 737-800 under the command of a Training Captain occupying the supernumerary crew seat touched down off an ILS Cat 1 approach 870 metres short of the runway at Katowice in fog at night with the AP still engaged. The somewhat protracted investigation did not lead to a Final Report until over 10 years later. This attributed the accident to crew failure to discontinue an obviously unstable approach and it being flown with RVR below the applicable minima. The fact that the commander was not seated at the controls was noted with concern.)
  • B738, Lyon France, 2009 (Synopsis: On 29 August 2009, an Air Algérie Boeing B737-800 departed the side of the runway during take off but then regained the paved surface after sustaining damage from obstructions, completed the take off without further event and continued to destination. Damage to one of the engines, to tyres and to two lights was discovered at the destination. ATC remained unaware of the excursion until the Operator asked its representative at Lyon to ask the airport to carry out a runway inspection.)
  • B738, Manchester UK, 2003 (Synopsis: 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.)
  • B738, Mangalore India, 2010 (Synopsis: 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)
  • B738, Perth Australia, 2008 (Synopsis: On 9 May 2008, a Boeing 737-800 made a low go around at Perth in good daylight visibility after not approaching with regard to the temporarily displaced runway threshold. A second approach was similarly flown and, having observed a likely landing on the closed runway section, ATC instructed a go around. However, instead, the aircraft flew level at a low height over the closed runway section before eventually touching down just beyond the displaced threshold. The Investigation found that runway closure markings required in Australia were contrary to ICAO Recommendations and not conducive to easy recognition when on final approach.)
  • B738, en-route, south west of Beirut Lebanon, 2010 (Synopsis: On 25 January 2010, a Boeing 737-800 being operated by Ethiopian Airlines on a scheduled passenger flight from Beirut to Addis Ababa in night IMC disappeared from ATC radar soon after departure from Runway 21 and was subsequently found to have impacted the sea in an unintentional out of control condition some five miles south west of the airport less than five minutes after getting airborne Impact resulted in the destruction of the aircraft and the death of all 90 occupants.)
  • B738, vicinity Christchurch New Zealand, 2011 (Synopsis: On 29 October 2011, a Boeing 737-800 on approach to Christchurch during the 68 year-old aircraft commander's annual route check as 'Pilot Flying' continued significantly below the applicable ILS minima without any intervention by the other pilots present before the approach lights became visible and an uneventful touchdown occurred. The Investigation concluded that the commander had compromised the safety of the flight but found no evidence to suggest that age was a factor in his performance. A Safety Recommendation was made to the Regulator concerning the importance of effective management of pilot check flights.)
  • B738, vicinity Trivandrum India, 2015 (Synopsis: On 18 August 2015, a Boeing 737-800 made three unsuccessful ILS approaches at Cochin around dawn then diverted to Trivandrum where a day VOR approach was unsuccessful and a MAYDAY was declared due low fuel. Two further supposedly visual approaches were attempted there before a third such "visual" approach - which involved ignoring EGPWS PULL UP Warnings in IMC - was followed by a successful landing with 349kg fuel remaining. The Investigation found that aircraft safety had been jeopardised and that Cochin ATC had not communicated information on the deteriorating weather at Trivandrum. Relevant operator procedures were considered as inadequate.)
  • B742, Brussels Belgium, 2008 (Synopsis: On 25 May 2008 a Kalitta Air B747-200F, which was departing Brussels on a cargo flight to Bahrain, overran Runway 20 at Brussels Airport, Belgium during a rejected take-off. The aircraft came to a stop 300m beyond the end of runway 20 and broke into three parts. The crew of four and one passenger safely evacuated from the aircraft and suffered only minor injuries.)
  • B742, Halifax Canada, 2004 (Synopsis: On 14 October 2004, a B742 crashed on take off from Halifax International Airport, Canada, and was destroyed by impact forces and a post-crash fire. The crew had calculated incorrect V speeds and thrust setting using an EFB.)
  • B743, vicinity Won Guam Airport, Guam, 1997 (Synopsis: On 6 August 1997, Korean Air flight 801, a Boeing 747-300, crashed at night at Nimitz Hill, 3 miles southwest of Won Guam International Airport, Agana, Guam while on final approach for runway 6 Left. Of the 254 persons on board, 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries.)
  • B744 / B763, Melbourne Australia, 2006 (Synopsis: On 2 February 2006, a Boeing 747-400 was taxiing for a departure at Melbourne Airport. At the same time, a Boeing 767-300 was stationary on taxiway Echo and waiting in line to depart from runway 16. The left wing tip of the Boeing 747 collided with the right horizontal stabiliser of the Boeing 767 as the first aircraft passed behind. Both aircraft were on scheduled passenger services from Melbourne to Sydney. No one was injured during the incident.)
  • B744, vicinity Bishkek Kyrgyzstan, 2017 (Synopsis: On 16 January 2017, the crew of a Boeing 747-400F failed to successfully complete a night auto-ILS Cat 2 approach at Bishkek and the aircraft crashed and caught fire. The 4 occupants and 35 others on the ground were killed and another 37 on the ground seriously injured. The ongoing Investigation has found that although the ILS localiser was captured and tracked normally, the aircraft remained above the glideslope throughout and flew overhead the runway before crashing just beyond it after initiation of a go around at DH was delayed. No evidence of relevant airworthiness issues has yet been found.)
  • B752 / CRJ7, San Francisco CA USA, 2008 (Synopsis: On 13 January 2008, a Boeing 757-200 and a Bombardier CL-600 received pushback clearance from two adjacent terminal gates within 41 seconds. The ground controller believed there was room for both aircraft to pushback. During the procedure both aircraft were damaged as their tails collided. The pushback procedure of the Boeing was performed without wing-walkers or tail-walkers.)
  • B752, Newark NJ USA, 2006 (Synopsis: On 28 October 2006, a Boeing 757-200 being flown by two experienced pilots but both with low hours on type was cleared to make a circling approach onto runway 29 at Newark in night VMC but lined up and landed without event on the parallel taxiway. They then did not report their error and ATC did not notice it after Airport Authority personnel who had observed it advised ATC accordingly, the pilots admitted their error.)
  • B762 / A310, Toronto Canada, 2001 (Synopsis: On 23 October 2001, at Toronto Pearson Airport, a B767 cleared for take-off was forced to reject the take-off when a tractor towing an A310 crossed the runway ahead of it. The tractor had been cleared to cross the active runway by ATC.)
  • B762, vicinity Busan Korea, 2002 (Synopsis: On 15 April 2002, a Boeing 767-200 attempting a circling approach at Busan in poor visibility crashed into terrain after failing to follow the prescribed procedure or go around when sight of the runway was lost. 129 of the 166 occupants were killed. The Investigation attributed the accident to actions and inactions of the pilots but noted that the aircraft operator bore considerable contextual responsibility for the poor crew performance. It was also concluded that ATC could have done more to manage the risk procedurally and tactically on the day and that ATM regulatory requirements did not adequately address risk.)
  • B772, San Francisco CA USA, 2013 (Synopsis: 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.)
  • BE20, vicinity North Caicos British West Indies, 2007 (Synopsis: On 6 February 2007, a Beech King Air 200 on a scheduled passenger flight crashed into water soon after making a dark night VMC take off and initial climb from North Caicos. The Investigation noted that the regulatory requirement for a crew of two pilots had been ignored and that the pilot had probably consumed alcohol within the permitted limits prior to the take off. It was concluded that he had probably lost spatial awareness and been in the process of attempting recovery to the originally intended flight path when impact occurred.)
  • C208, vicinity Pelee Island Canada, 2004 (Synopsis: On 17 January, 2004 a Cessna 208 Caravan operated by Georgian Express, took off from Pellee Island, Ontario, Canada, at a weight significantly greater than maximum permitted and with ice visible on the airframe. Shortly after take off, the pilot lost control of the aircraft and it crashed into a frozen lake.)
  • C212, en-route, Bamiyan Afghanistan, 2004 (Synopsis: On 27 November 2004, a CASA C212 operated by Presidential Airways, crashed in moutainous terrain near Bamiyan, Afghanistan. The aircraft stalled while trying to climb over a ridge.)
  • C25A / Vehicle, Reykjavik Iceland, 2018 (Synopsis: On 11 January 2018, a privately-operated Cessna 525A Citation with a two-pilot English-speaking crew made a night takeoff from Reykjavik without clearance passing within “less than a metre” of a vehicle sanding the out-of-service and slippery intersecting runway as it rotated. The Investigation noted that the takeoff without clearance had been intentional and due to the aircraft slipping during the turn after backtracking. It also noted that the vehicle was operating as cleared by the TWR controller on a different frequency and that information about it given to an inbound aircraft on the TWR frequency had been in Icelandic.)
  • C525 / B773, vicinity London City UK, 2009 (Synopsis: On 27 July 2009, a Cessna 525 departing from London City failed to comply with the initial 3000 ft QNH SID Stop altitude and at 4000 ft QNH in day VMC came into close proximity on an almost reciprocal heading with a Boeing 777-300ER. Actual minimum separation was approximately 0.5nm laterally and estimated at between 100 ft and 200 ft vertically.)
  • CL60, Teterboro USA, 2005 (Synopsis: 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.)
  • CRJ2, Charleston WV USA, 2010 (Synopsis: On 19 January 2010, PSA Airlines CRJ 200 began take off from Charleston with an incorrect flap setting. After late crew recognition, a rejected take off was commenced at V1+13KIAS and an overrun into the EMAS bed at approximately 50knots followed. It was noted that had the overrun occurred prior to installation of the EMAS bed, the aircraft would probably have run down the steep slope immediately after the then-available RESA. The flap setting error was attributed non-adherence to a sterile flight deck. The late reject decision to an initial attempt to correct the flap error during the take off.)
  • CRJ2, en-route, Jefferson City USA, 2004 (Synopsis: On October 14, 2004, a Bombardier CRJ-200 being operated by Pinnacle Airlines on a non revenue positioning flight crashed into a residential area in the vicinity of Jefferson City Memorial Airport, Missouri after the flight crew attempted to fly the aircraft beyond its performance limits and a high altitude stall, to which their response was inappropriate, then followed.)
  • CRJ2, en-route, south of Santander Spain, 2009 (Synopsis: On 24 February 2009, the Captain of a CRJ 200 being operated by Air Nostrum on a passenger flight from Madrid to Santander inadvertently shut down both engines simultaneously during the descent but a successful restart was rapidly achieved and the remainder of the flight was uneventful. The subsequent investigation concluded that the shutdown was the consequence of both violation of procedure and lack of knowledge of the Captain involved.)
  • DH8A, Saulte Ste. Marie ON Canada, 2015 (Synopsis: On 24 February 2015, the crew of a Bombardier DHC8-100 continued an already unstable approach towards a landing despite losing sight of the runway as visibility deteriorated in blowing snow. The aircraft touched down approximately 140 metres before the start of the paved surface. The continued unstable approach was attributed by the Investigation to "plan continuation bias" compounded by "confirmation bias". It was also found that although the aircraft operator had had an approved SMS in place for almost six years, it had not detected that approaches made by the aircraft type involved were routinely unstable.)
  • DH8D / B735, Exeter UK, 2009 (Synopsis: On 30 October 2009, a Bombardier DHC8-400 departing Exeter at night failed to stop as cleared at the runway 08 holding point and continued onto the runway on which a Boeing 737-500 had just touched down on in the opposite direction. The Investigation attributed the DHC8-400 crew error to distraction arising from failure to follows SOPs and poor monitoring of the Captain taxiing the aircraft by the First Officer. The failure of the DHC8 crew to immediately report the occurrence to Flybe, which had resulted in non-availability of relevant CVR data to the Investigation was also noted.)
  • DHC6, en-route, Arghakhanchi Western Nepal, 2014 (Synopsis: On 16 February 2014 a Nepal Airlines DHC6 attempting a diversion on a VFR flight which had encountered adverse weather impacted terrain at an altitude of over 7000 feet in a mountainous area after intentionally entering cloud following a decision to divert due to weather incompatible with VFR. The aircraft was destroyed and all 18 occupants were killed. The Investigation attributed the accident to loss of situational awareness by the aircraft commander and inadequate crew co-operation in responding to the prevailing weather conditions.)
  • DHC6, vicinity Saint Barthelemy French Antilles, 2001 (Synopsis: On 24 March 2001, a De Havilland DHC-6, operated by Caraïbes Air Transport, lost control during a VFR approach to Saint Barthelemy airport in the French Antilles. On short final the aircraft took a sharp left turn which resulted in impact with the terrain.)
  • E145, Ljubljana Slovenia, 2010 (Synopsis: On 24 May 2010 the crew of a Regional Embraer 145 operating for Air France continued an unstable visual approach at Ljubljana despite breaching mandatory go-around SOPs and ignoring a continuous EGPWS ‘PULL UP’ Warning. The subsequent touchdown was bounced and involved ground contact estimated to have been at 1300fpm with a resultant vertical acceleration of 4g. Substantial damage was caused to the landing gear and adjacent fuselage. It was concluded that the type-experienced crew had mis-judged a visual approach and then continued an unstabilised approach to a touchdown with the aircraft not properly under control.)
  • E170, Frankfurt Germany, 2005 (Synopsis: On 1 March 2005, an Embraer ERJ 170 inbound to Frankfurt was intentionally flown below the ILS Glideslope in good night visibility by the First Officer after disconnection of the Autopilot at approximately 340 feet agl in order to achieve an early turn off after touchdown as a means to catch up some of the delay to the flight. The result was impact with the approach lighting and touchdown before the beginning of the runway. Significant damage to the aircraft was found once it had reached the designated parking gate.)
  • E190 / Vehicle, Paris CDG France, 2014 (Synopsis: On 19 April 2014, an Embraer 190 collided with the tug which was attempting to begin a pull forward after departure pushback which, exceptionally for the terminal concerned, was prohibited for the gate involved. As a result, severe damage was caused to the lower fuselage. The Investigation found that the relevant instructions were properly documented but ignored when apron services requested a 'push-pull' to minimise departure delay for an adjacent aircraft. Previous similar events had occurred on the same gate and it was suspected that a lack of appreciation of the reasons why the manoeuvre used was prohibited may have been relevant.)
  • E190, Kupang Indonesia, 2015 (Synopsis: 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.)
  • EC55, en-route, Hong Kong China, 2003 (Synopsis: On 26 August 2003, at night, a Eurocopter EC155, operated by Hong Kong Government Flight Service (GFS), performing a casualty evacuation mission (casevac), impacted the elevated terrain in Tung Chung Gap near Hong Kong International airport.)
  • EUFI / A321, en-route, near Clacton UK, 2008 (Synopsis: On 15 October 2008, following participation in a military exercise over East Anglia (UK), a formation of 2 foreign Eurofighters entered busy controlled airspace east north east of London without clearance while in the process of trying to establish the required initial contact with military ATC, resulting in loss of prescribed separation against several civil aircraft.)
  • F15 / E145, en-route, Bedford UK, 2005 (Synopsis: On 27 January 2005, two USAF-operated McDonnell Douglas F15E fighter aircraft, both continued to climb and both passed through the level of an Embraer 145 being operated by British Airways Regional on a scheduled passenger flight from Birmingham to Hannover, one seen at an estimated range of 100 feet.)
  • F27, vicinity Sharjah UAE, 2004 (Synopsis: 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.)
  • F50, vicinity Luxembourg, 2002 (Synopsis: 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.)
  • FA20, vicinity Narsarsuaq Greenland, 2001 (Synopsis: 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 (Synopsis: 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.)
  • GLF4, Teterboro NJ USA, 2010 (Synopsis: 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.)
  • H25B, vicinity Akron OH USA, 2015 (Synopsis: 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.)
  • HUNT, manoeuvring, vicinity Shoreham UK, 2015 (Synopsis: 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.)
  • IL76, vicinity Karachi Pakistan, 2010 (Synopsis: 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.)
  • JS31, Kärdla Estonia, 2013 (Synopsis: 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.)
  • L101, vicinity Riyadh Saudi Arabia, 1980 (Synopsis: 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.)
  • L410, Isle of Man, 2017 (Synopsis: 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 (Synopsis: 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.)
  • LJ35, vicinity Masset BC Canada, 1995 (Synopsis: 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.)
  • MA60, vicinity Kaimana West Papua Indonesia, 2011 (Synopsis: 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.)
  • MD82, Detroit MI USA, 1987 (Synopsis: 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, Little Rock USA, 1999 (Synopsis: On 1 June 1999, an MD82 belonging to American Airlines, overran the end of the runway during landing. The captain and 10 passengers were killed.)
  • MD82, Madrid Barajas Spain, 2008 (Synopsis: 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.)
  • MD82, en-route, near Machiques Venezuela, 2005 (Synopsis: 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.)
  • MD83, Are/Ostersund Sweden, 2007 (Synopsis: 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.)
  • MD83, vicinity Lagos Nigeria, 2012 (Synopsis: 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.)
  • MD87 / C525, Milan Linate, 2001 (Synopsis: 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.)
  • MD88, Groningen Netherlands, 2003 (Synopsis: 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.)
  • RJ1H, vicinity Zurich Switzerland, 2001 (Synopsis: On 24 November 2001, a Crossair Avro RJ100 making a night non precision approach to Zurich violated approach minima and subsequently impacted terrain whilst making a delayed attempt to initiate a go around. The aircraft was destroyed by the impact and post crash fire and 24 of the 33 occupants were killed. The Investigation attributed the crash to the crew deliberately continuing descent below MDA without having acquired the prescribed visual reference. Both crew pairing and aspects of the crew as individuals were identified as the context.)
  • RJ85, en-route, north of Tampere Finland 2009 (Synopsis: On 17 December 2009, a Blue 1 Avro RJ85 experienced progressive fuel starvation during continued flight after the crew had failed to carry out the QRH drill for an abnormal fuel system indication caused by fuel icing. Although hindsight was able to confirm that complete fuel starvation had not been likely, a failure to recognise the risk to fuel system function arising from routine operations in very cold conditions was identified by the subsequent investigation.)
  • SB20, Stockholm Arlanda, 2001 (Synopsis: On 18 December 2001, a Saab 2000 being operated by Air Botnia on scheduled passenger flight from Stockholm to Oulu was taxiing out at night in normal visibility in accordance with its ATC clearance when a car appeared from the left on a roadway and drove at speed on a collision course with the aircraft. In order to avoid a collision, the aircraft had to brake sharply and the aircraft commander saw the car pass under the nose of the aircraft and judged the vehicle’s closest distance to the aircraft to be four to five metres. The car did not stop, could not subsequently be identified and no report was made by the driver or other witnesses. The diagram below taken from the official report shows the site of the conflict - the aircraft was emerging from Ramp ‘G’ to turn left on taxiway ‘Z’ and the broken line shows the roadway which is crossed just before the left turn is commenced.)
  • SF34, Marsh Harbour Bahamas, 2013 (Synopsis: 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.)
  • SF34, New York JFK USA, 1999 (Synopsis: An SF34 overan New York JFK 04R after an unstabilised ILS approach in IMC was continued to a deep landing at excessive speed and the aircraft overan into the installed EMAS.)
  • SF34, vicinity Mariehamn Finland, 2012 (Synopsis: On 14 February 2012 a Latvian-operated Saab 340 acknowledged an ATC clearance to make a procedural ILS approach to Mariehamn and then completely disregarded the clearance by setting course direct to the aerodrome. Subsequently, having lost situational awareness, repeated GPWS PULL UP warnings at night in VMC were ignored as control of the aircraft was lost with a recovery only achieved an estimated 2 seconds before ground impact would have occurred and then followed by more ignored PULL UP Warnings due to continued proximity to terrain before the runway was sighted and a landing achieved.)
  • SH36, vicinity Oshawa ON Canada, 2004 (Synopsis: On 16 December 2004, an Air Cargo Carriers Shorts SD3-60 attempted to land at Oshawa at night on a runway covered with 12.5mm of wet snow which did not offer the required landing distance. After unexpectedly poor deceleration despite selection of reverse propeller pitch, full power was applied and actions for a go around were taken. Although the aircraft then became airborne in ground effect, it subsequently failed to achieve sufficient airspeed to sustain a climb and an aerodynamic stall was followed by impact with terrain and trees beyond the end of the runway. The aircraft was substantially damaged and both pilots sustained serious injuries but there was no post-crash fire)
  • SW4, Cork Ireland, 2011 (Synopsis: 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.)
  • SW4, Sanikiluaq Nunavut Canada, 2012 (Synopsis: 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.)
  • SW4, en-route, North Vancouver BC Canada, 2015 (Synopsis: On 13 April 2015, a Swearingen SA226 Metro II which had recently departed on a cargo flight was climbing normally when it suddenly entered an unexplained and steep descent a few minutes after takeoff. There were no communications from the pilots. It was later found to have impacted terrain after a rate of descent exceeding 30,000 fpm had created aerodynamic forces which caused structural disintegration to begin before impact. The Investigation could not determine why but concluded that “alcohol intoxication almost certainly played a role” and noted that indications that the Captain was a chronic alcoholic had not prompted any intervention.)
  • SW4, en-route, Taranaki Province New Zealand, 2005 (Synopsis: On 3 May 2005, Fairchild-Swearingen SA227 (Metro III), operated by Airwork (NZ) Limited, was on a night air transport freight flight when it suffered a loss of control which developed into a spiral dive. The crew did not recover the control and the aircraft became overstressed which resulted in an in-flight break up and terrain impact, killing both crewmembers.)
  • T154, vicinity Smolensk Russian Federation, 2010 (Synopsis: 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.)
  • TOR / C152, en-route, Mattersey Nottinghamshire UK, 1999 (Synopsis: On 21 January 1999, a UK Royal Air Force Tornado GR1 and a private Cessna 152 collided in mid air, at low level in day VMC with the resultant loss of both aircraft and the death of all occupants.)
  • Vehicle / PA31, Mackay SE Australia, 2008 (Synopsis: On 29 June 2012, a Piper PA31 taking off from runway 05 on a passenger charter flight just missed hitting an inspection vehicle which had entered the take off runway from an intersecting one contrary to ATC clearance. The overflying aircraft was estimated to have cleared the vehicle by approximately 20 feet and the pilot was unaware it had entered the active runway. The driver had been taking a mobile telephone call at the time and attributed the incursion to distraction. The breached clearance had been given and correctly read back approximately two minutes prior to the conflict occurring.)