AEROTHRIVE

Accident of TWA Flight 843: Runway Overrun Results in Fire On July 30, 1992, a Lockheed L-1011 TriStar operated as TWA Flight 843 sustained substantial damage during a rejected takeoff at John F. Kennedy International Airport in New York. All 292 occupants survived, although 10 passengers suffered minor injuries. The aircraft was destroyed by fire after the incident. The sequence began during takeoff from runway 13R when the stick shaker, indicating an imminent stall, erroneously activated shortly after liftoff. The first officer, startled by the activation, transferred control to the captain without clear verbal coordination. Believing the aircraft might not be performing as expected, the captain decided to abort the takeoff at an altitude of just 14 feet (4.3 meters) and a speed of 170 knots. This decision contravened standard procedures, which mandate continuing takeoff once rotation speed (VR) is reached. Despite applying full reverse thrust and maximum braking, the aircraft overran the runway and came to rest on grass 296 feet beyond the pavement. A hard landing had ruptured the right wing, causing fuel to spill and ignite. The crew and off-duty attendants managed a rapid evacuation, with only three exits usable. Emergency responders contained the fire effectively. The investigation by the National Transportation Safety Board (NTSB) revealed significant contributing factors. A defective Angle of Attack (AoA) sensor, previously flagged as unreliable on nine occasions, triggered the stick shaker. Maintenance practices allowed the faulty component to be reused without conclusive repair. TWA's quality assurance systems failed to identify these lapses. The investigation also highlighted deficiencies in Crew Resource Management (CRM). The lack of a pre-departure briefing left responsibilities during abnormal situations undefined. The abrupt transfer of control during a critical phase compounded the problem. Additionally, procedural gaps meant crews were not adequately trained to recognize false stick shaker activations or execute coordinated responses. TWA subsequently overhauled its CRM protocols, maintenance standards, and pre-flight procedures to address the identified shortcomings. These changes aimed to prevent recurrence of similar incidents, enhancing both operational safety and compliance management. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

Fatal Crash of Thai Airways International Flight 311: Miscommunication and High Workload On July 31, 1992, Thai Airways International Flight 311, an Airbus A310-304 en route from Bangkok to Kathmandu, impacted terrain in Nepal's Langtang National Park during approach, killing all 113 occupants. The accident was the result of a controlled flight into terrain (CFIT), with multiple contributing factors linked to operational errors, communication deficiencies, and inadequate training. The aircraft, operating in complex terrain under instrument meteorological conditions, experienced a minor malfunction in the inboard trailing flaps shortly after reporting the "Sierra" waypoint. This raised concerns about executing a challenging approach into Kathmandu. The captain initially decided to divert to Calcutta but reversed this decision when the flaps resumed normal operation. However, coordination and communication issues exacerbated the situation. The captain, with 13,200 flight hours, faced increased frustration from unclear and insufficient responses from the first officer and Nepalese air traffic control (ATC). ATC, limited by a lack of radar and minimal situational awareness, failed to provide clear instructions or weather updates. The controller, inexperienced and poorly supervised, deferred terrain separation responsibilities to the pilots. Language barriers and procedural misunderstandings further complicated communication. As the captain struggled with a high workload and degraded situational awareness, the flight deviated north of the airport into mountainous terrain. The ground proximity warning system (GPWS) activated moments before the crash, but the captain dismissed the warnings as erroneous. The aircraft collided with a rock face at 11,500 feet, at a ground speed of 300 knots. Investigations by Nepalese authorities, Airbus, and Canadian safety experts revealed systemic issues. The first officer’s lack of assertiveness, inadequate simulator training for Kathmandu’s approach, improper flight management system usage, and Thai Airways’ failure to prepare crews for complex operational scenarios were key findings. ATC shortcomings, including insufficient oversight and language proficiency, significantly contributed to the accident. Safety improvements following the investigation included mandatory simulator training for Kathmandu operations and enhanced ATC supervision and language training in Nepal. However, these measures came only after a second CFIT accident in the same region later that year, underscoring systemic gaps in procedural and training frameworks. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

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PIA Flight 268: Early Descent Error Causes Fatal Crash On September 28, 1992, Pakistan International Airlines Flight 268, an Airbus A300B4-103 registered as AP-BCP, crashed into the Mahabharat Range during approach to Kathmandu’s Tribhuvan International Airport, resulting in the deaths of all 167 individuals on board. The controlled flight into terrain (CFIT) incident remains Nepal’s deadliest aviation disaster and the most severe accident in PIA’s history. The flight, originating from Karachi, was conducting the complex "Sierra approach," requiring precise altitude adjustments at several distance-measuring equipment (DME) checkpoints. Investigators found that the aircraft initiated each descent step prematurely, placing it significantly below the required altitudes at various points. At 16 DME, it was 1,000 feet below the prescribed level, and at 10 DME, the discrepancy had increased to 1,300 feet. The aircraft collided with a mountain ridge at approximately 7,300 feet, south of the designated safe crossing altitude of 9,500 feet. Key factors contributing to the accident included pilot error, insufficiently clear navigational charts, and limited intervention by Nepalese air traffic controllers. While the flight crew accurately reported their altitudes, controllers failed to challenge their descent profile until moments before the impact. Visibility challenges due to overcast weather and the steep terrain further complicated situational awareness. Additionally, the Ground Proximity Warning System (GPWS) activated too late to prevent the crash. The accident investigation highlighted deficiencies in the approach plates issued to PIA pilots, which were deemed ambiguous. Recommendations included revisions to standardize navigational charts under ICAO guidelines and modifications to simplify the Sierra approach. Nepalese air traffic controllers' hesitancy to assertively manage deviations in terrain separation was also identified as a systemic issue. Despite these findings, no mechanical faults or terrorism were implicated. The absence of critical cockpit voice recordings hampered insights into the crew's decision-making process, although the flight data recorder provided sufficient evidence to outline the sequence of errors leading to the crash. This incident underscored the complexities of terrain-challenged approaches and the necessity for precise procedural compliance, clear communication, and robust charting to mitigate CFIT risks in similar operational contexts. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

Martinair Flight 495: Deadly Crash Linked to Severe Weather and Pilot Actions On December 21, 1992, Martinair Flight 495, a McDonnell Douglas DC-10-30CF, crashed during a landing attempt at Faro Airport, Portugal. The flight, originating from Amsterdam, encountered extreme weather conditions, including heavy rain, strong winds, and microbursts, which contributed to the loss of control. Of the 340 individuals on board, 56 lost their lives, while 106 sustained serious injuries. The final approach was characterized by a high sink rate and manual flight control in conditions of reduced visibility and turbulence. Portuguese investigators highlighted multiple contributing factors, including pilot decision-making and the challenging operational environment. The aircraft experienced a hard landing that exceeded the structural limits of its right landing gear, leading to its collapse. This triggered the separation of the right wing, rupture of a fuel tank, and subsequent fire. The fuselage split into two sections, exacerbating injuries and fatalities. A critical factor identified by investigators was the crew's mismanagement of the approach. The decision to disable the autopilot during the landing phase introduced instability in the final moments. Premature engine power reduction further compromised control. While weather conditions, particularly windshear, were prominent in Portuguese and Dutch reports, pilot error, particularly in adapting to the adverse conditions, was also highlighted as a significant contributor. The incident report also pointed to deficiencies in airport infrastructure. The absence of an advanced approach lighting system and challenges in accurately communicating wind and runway conditions to the crew compounded operational risks. Subsequent legal and investigative proceedings raised concerns about maintenance practices and incomplete black box data. Allegations of improper pilot training and overlooked technical issues, including deferred landing gear replacements, added complexity to the safety review process. While partial liability was later attributed to the Dutch state, the accident underscored the critical interplay of environmental factors, crew decision-making, and infrastructure readiness in aviation safety. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

Loss of Situational Awareness in Challenging Conditions leads to fatal Crash of Aviateca Flight 901 On August 9, 1995, Aviateca Flight 901, a Boeing 737-2H6 registered as N125GU, impacted the San Vicente volcano in El Salvador during its approach to Comalapa International Airport. All 65 occupants on board perished, marking it as the deadliest aviation disaster in the country's history. The aircraft, operating a scheduled passenger service from Miami to San José, Costa Rica, had logged 16,645 flight hours and 20,323 cycles. Its crew included a captain and first officer with prior military backgrounds and a combined total of over 14,500 flight hours. Departing Guatemala City with a two-hour delay, the flight encountered severe weather en route to San Salvador. Deviating from the standard approach along Airway G346, the captain sought to intercept the Instrument Landing System (ILS) for Runway 07 rather than the more conventional Runway 25. This deviation was neither communicated effectively to air traffic control (ATC) nor fully managed by the flight crew. Compounding the issue, the ATC controller instructed the flight to descend to 5,000 feet without precise knowledge of the aircraft's position relative to the surrounding terrain. While descending, the aircraft’s Ground Proximity Warning System (GPWS) activated, signaling the crew to take immediate corrective action. Despite applying full engine power, the aircraft struck the San Vicente volcano at 5,773 feet, approximately 12 miles northeast of the airport. The crash scattered debris over a 500-square-yard area, with challenging weather and terrain hampering rescue efforts. The Civil Aviation Authority attributed the primary cause to the flight crew’s loss of situational awareness concerning the 7,159-foot volcanic obstacle. Contributory factors included ineffective crew resource management and inadequate ATC oversight during adverse weather conditions. Safety recommendations stemming from the investigation emphasized enhanced crew training in situational awareness and adherence to standard approach procedures, alongside improvements in ATC radar and communication protocols. This case underscores the interplay of human factors and operational compliance in controlled flight into terrain (CFIT) scenarios. https://lnkd.in/e6QWaFgz https://lnkd.in/eyEhve5j

China Airlines Flight 611 : Crash in to the Sea Due to Fatigue Cracking China Airlines Flight 611, operated by a Boeing 747-209B, disintegrated mid-air on May 25, 2002, over the Taiwan Strait while en route from Taoyuan Airport in Taiwan to Hong Kong. The accident, which remains Taiwan's deadliest aviation incident, resulted in the deaths of all 225 occupants. The cause of the catastrophic breakup was traced back to metal fatigue, stemming from a substandard repair carried out in 1980 following a tailstrike on the aircraft. Instead of following Boeing's Structural Repair Manual (SRM), which mandates either complete skin replacement or extensive reinforcement to restore structural integrity, maintenance personnel installed a doubler plate over the damaged area, failing to properly contain existing scratches and cracks. This inadequate repair did not fully cover the affected fuselage area; as a result, over 22 years and thousands of pressurization cycles, the cracks propagated. On the day of the accident, the accumulated fatigue finally caused a structural rupture near the aft fuselage at section 46, which led to a rapid decompression that separated the rear fuselage and engine mounts at an altitude of approximately 35,000 feet. The subsequent descent caused the engines to detach, while the remaining fuselage sections descended separately into the sea. Similarities to the 1985 Japan Airlines Flight 123 incident, which also involved a Boeing 747 and a faulty tailstrike repair, underscore the consequences of non-compliance with repair protocols. During Flight 611’s investigation, it was noted that maintenance logs contained images of tar stains, likely due to on-board smoking prior to 1995, which may have visually indicated cracks beneath the doubler plate, suggesting the issue could have been detected earlier. The accident has since prompted heightened regulatory focus on adherence to SRM standards and reinforced inspection protocols for older aircraft. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

Crash of Korean Air Cargo Flight 8509: Instrument Failure and CRM Breakdown On December 22, 1999, Korean Air Cargo Flight 8509, a Boeing 747-2B5F en route to Milan from London Stansted Airport, crashed shortly after takeoff due to erroneous data from the captain’s attitude director indicator (ADI), which was affected by a previously identified inertial navigation unit (INU) malfunction. The flight had faced an INU-related issue on the prior leg from Tashkent, where an INU providing data to the captain's ADI displayed inaccurate roll information. Although maintenance efforts at Stansted involved a repair to a connector on the ADI, engineers lacked the correct Fault Isolation Manual and misinterpreted a successful test of the ADI as evidence of a resolution, leaving the INU problem unaddressed. The incident escalated during the nighttime departure from Stansted as the aircraft entered clouds at 400 feet, and the captain’s ADI—continuing to receive faulty data—failed to show that the aircraft was in a left bank. A comparator alarm signaled discrepancies between the captain’s and first officer’s ADIs, but ineffective Crew Resource Management (CRM) practices meant critical cues went unaddressed. Although the first officer’s ADI displayed the correct aircraft orientation, he did not verbally challenge the captain, whose experience far exceeded his own, nor did he attempt to take control. The flight engineer, more experienced than the first officer, issued partial warnings, noting the bank indicator failure 20 seconds before impact and repeating “Bank, bank” and additional observations. However, his warnings were uncoordinated, and no corrective action was taken by the captain, who continued adjusting controls toward a deeper left bank. Data from the flight recorders indicated the control inputs continued to command a left bank until impact, with the aircraft ultimately colliding with terrain near Great Hallingbury, England, at a steep angle of 40° nose-down and 90° left bank. The impact destroyed the aircraft and resulted in the deaths of all four crew members on board. Following this crash, the UK’s Air Accidents Investigation Branch (AAIB) recommended that Korean Air enhance its CRM protocols and flight training programs to incorporate assertive communication practices and address specific cultural dynamics that may hinder junior crew members from speaking up during critical situations. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

Navigation Errors leads to Fatal Crash of Garuda Indonesia Flight 152 On September 26, 1997, Garuda Indonesia Flight 152, an Airbus A300B4-220, was en route from Soekarno–Hatta International Airport to Polonia International Airport, Medan. As the aircraft approached Medan, adverse weather conditions created visibility challenges, which led air traffic controllers (ATC) to guide the crew for an instrument landing system (ILS) approach to Runway 5. Communication errors began when the Medan ATC mistakenly used the callsign "Merpati 152"—a mix-up with another flight that had been in the same area earlier. When ATC later corrected the callsign to "Indonesia 152," confusion was introduced in the instructions for positioning on the south (right) side of the runway. The absence of explicit confirmation led the Garuda crew to proceed as if approaching from the north, based on standard procedures and the approach chart. As ATC instructed the crew to turn right and descend to 2,000 feet, the crew initially turned left, attempting to align with their perception of the correct approach. The First Officer soon realized the aircraft was turning in the wrong direction and alerted the Captain, who then queried ATC. However, by this time, the discrepancy in directions, compounded by the Medan radar system’s 12-second update delay, prevented controllers from accurately tracking the flight's heading. This delay in information, combined with incomplete ATC guidance, left the crew unsure of their alignment with the runway. At a critical point, the flight descended below the instructed altitude of 2,000 feet. Focused on correcting the heading and altitude, the pilots failed to detect the approach of terrain. The aircraft's Flight Data Recorder (FDR) recorded an attempted corrective pitch and power increase moments before impact; however, the efforts were insufficient. Just seconds later, the plane struck treetops and crashed into a ravine 27 kilometers from the runway, resulting in the loss of all 234 onboard. The investigation highlighted several key issues: ATC’s initial misidentification and subsequent incomplete directions, the radar system's delay, and the crew's misinterpretation of approach procedures in low visibility. The accident underscored critical flaws in procedural clarity and situational awareness, prompting subsequent improvements in communication protocols and radar technology in similar operational environments. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!

TWA Flight 800: Explosion over the Atlantic Ocean On July 17, 1996, Trans World Airlines Flight 800, a Boeing 747-131 registered as N93119, was en route from New York's John F. Kennedy International Airport to Paris when it experienced a catastrophic in-flight explosion 12 minutes post-takeoff. The explosion resulted in the aircraft disintegrating midair over the Atlantic Ocean near East Moriches, New York, causing the loss of all 230 occupants. Subsequent investigations by the National Transportation Safety Board (NTSB) revealed probable causes rooted in the ignition of flammable vapors within the center wing fuel tank. The NTSB’s findings suggested that a short circuit likely ignited the vapors. While the exact source of ignition could not be conclusively determined, examination indicated electrical malfunctions in the aircraft’s fuel quantity indication system (FQIS). Notably, there were signs of wiring faults and arcing in the FQIS, potentially creating sparks within the volatile environment of the partially filled fuel tank. Investigators also identified abnormal FQIS readings noted by the flight crew shortly before the explosion. The captain described these indications as "crazy," reflecting erratic fuel gauge behavior, which was consistent with a potential wiring malfunction. Adding complexity to the situation, the NTSB identified issues with previous fuel tank maintenance. A mechanic had overridden the automatic volumetric shutoff (VSO) during refueling to complete tank filling, a procedure that had been a recurring requirement in prior maintenance logs for this aircraft. The VSO override involved manipulating the volumetric fuse and overflow circuit breaker, a practice raising questions about its impact on tank pressurization and system stability. Following the incident, the investigation was characterized by collaborative efforts from multiple agencies, including the FBI, due to initial terrorism suspicions. The joint efforts involved extensive underwater search and recovery operations, eventually reconstructing over 95% of the aircraft at the former Grumman Aircraft hangar in Calverton, New York. As a direct outcome of the NTSB's findings, regulatory changes were implemented to mitigate the risk of similar incidents. These changes included mandates for improved fuel tank safety measures, such as installing inerting systems to reduce flammable vapors within fuel tanks. Subscribe to our Aviation Safety Newsletter NOW and get the hot stuff free and without delay: https://lnkd.in/eGZqhPHR! Visit https://AEROTHRIVE.com for professional training courses, audits and solutions in aviation safety, compliance, quality and operations!