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Yemenia Reports, Appendix 8, 9, Final

Yemen Airways 70-ADJ, flight IY626 to Moroni

Appendix 8 and 9

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    Mozambique Plane Crash Final Report


    On Jan 9th 2014 Namibia’s Accident Investigation Commission released the preliminary report of the LAM E190 crash over Botswana/Namibia on Nov 29th 2013. The conclusion at that time was that the captain intentionally crashed the aircraft. On November 29, 2013, there were 28 passengers and 6 crew aboard the Embraer ERJ-190 flown by LAM Linhas Aereas de Mocambique, and it was enroute at FL380 over northern Botswana when the flight descended and radio contact was lost. The burned out wreckage was located by villagers in Bwabwata National Park (Sambesi Region) on Nov 30. A news article on April 15 2016 indicated that the final report was released, although we have not verified it.

    The captain in charge of the aircraft, Herminio dos Santos Fernandes, was alone in the cockpit at the time of the crash. The copilot had left for the lavatory.

    The unverified article says that the final report was compiled by Theo Shilongo, deputy director of the directorate of aircraft accident investigations, who was the investigator in charge, and Hafeni Mweshixwa as the co-investigator. It was signed off by works and transport minister Alpheus Naruseb. When it is available to the public, it should be available at the Directorate of Aircraft Accident Investigations Namibia (DAAI).

    An interim report of the accident is below. The interim report indicates “The DAAI will provide updates on the investigation and safety recommendations as they become available until completion of the final report” in accordance with the provisions of ICAO Annex 13.

    2965
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    Revisiting Ethiopia Flight 409

    We’ve been studying Ethiopia Flight 409 for a while, and now that the official investigation Progress Report is out, we have looked at it with quite some interest. The 28 page report is attached as a pdf at the end of this editorial, so if you haven’t seen it yet, we have it handy–

    In some places, we find that the report corroborates some of the the points we made (or discovered in our research.)

    According to the report:

    “Instruments meteorological conditions prevailed for the flight, and the flight was on an instrument flight plan. The accident occurred at night in dark lighting conditions with reported isolated cumulonimbus clouds and thunderstorms in the area.”

    Their report also states:
    The Lebanese Civil Aviation Authority reviewed the data from the Lebanese Meteorological Services that was collected on 25 January, 2010 after the accident. Meteorological data revealed some significant meteorological conditions in the area at the time of the accident. Relevant meteorological documents are included in the investigation file and will be analyzed during the investigation.

    1.7.1 General meteorological situation
    At the time of the accident, there was thunderstorms activity southwest and west of the field, as well as to the northwest on the localizer path for runway 16.

    We had found a satellite photo of the area at the time in question and found something more turbulent than isolated cumulonumbus clouds. Here are the details we turned up
    (thanks to Prof. Robert H. Holzworth
    Departments of Earth and Space Sciences, and Physics
    Director, World Wide Lightning Location Network )

    WWLLN lightning strokes between (45,35.2) and (33.6, 35.7) coordinates on25 Jan 2010 between 00 and 06 UTC
    .
    2010/01/25,00:26:01.675091, 33.7925,  35.3157, 18.6, 15 2010/01/25,00:32:36.535404, 33.6762,  35.3223,  2.6,  5 2010/01/25,00:35:33.147928, 33.8152,  35.3989, 17.1,  9 2010/01/25,00:36:46.386409, 33.7880,  35.4182,  6.3,  6 2010/01/25,00:37:57.880969, 33.7473,  35.4083, 12.9,  8 2010/01/25,00:38:56.307703, 33.8144,  35.4480,  6.7,  5 2010/01/25,00:39:52.170965, 33.8098,  35.4486, 22.5, 1 02010/01/25,00:47:07.877656, 33.7658,  35.5138, 16.3,  7 2010/01/25,00:47:08.129640, 33.7532,  35.5187,  6.8,  5 2010/01/25,00:51:28.917459, 33.7313,  35.4897, 15.8,  8 2010/01/25,00:57:16.994854, 33.7712,  35.5668,  6.2,  5 2010/01/25,00:57:17.172976, 33.8877,  35.6009,  3.1,  5 2010/01/25,00:57:16.970924, 33.8230,  35.5664,  9.2,  5 2010/01/25,01:05:02.878083, 33.6379,  35.5348, 10.9,  5 2010/01/25,02:58:51.961652, 33.6073,  35.3703,  2.3,  5 2010/01/25,03:00:31.235850, 33.6450,  35.3881,  5.8,  7 2010/01/25,03:02:45.342786, 33.6157,  35.3553,  4.5,  7 2010/01/25,03:30:07.101084, 33.6511,  35.3185, 17.5,  7 2010/01/25,04:06:25.411422, 33.8432,  35.3648, 10.9,  5 2010/01/25,04:07:31.723296, 33.9087,  35.3844,  7.0,  5 2010/01/25,04:13:12.295902, 33.9543,  35.4151, 17.0, 10 2010/01/25,04:29:17.203911, 33.9865,  35.4613, 20.7, 10 2010/01/25,04:33:22.703869, 33.9637,  35.3229,  7.6,  6 2010/01/25,04:35:07.805894, 33.8709,  35.3297, 13.3,  8 2010/01/25,04:46:45.611497, 33.9634,  35.4145, 12.9,  6 2010/01/25,05:19:51.913652, 33.6442,  35.4520, 19.5,  8 2010/01/25,05:35:10.788571, 33.9139,  35.2087,  9.5,  7 2010/01/25,05:56:25.149281, 33.6332,  35.6535, 14.0,  7

    and the satellite photo:

    The plane’s on board radar would have normally registered this unacceptable massive super cell in the area where the airplane hit the ocean and the pilot would have adjusted the flight path accordingly. This makes us question if the on board radar was intact and operable. The weather system pictured in the satellite photo is not weather a pilot would voluntarily fly into. So we were not surprised to see this included in the report:

    1.17.1.6 Procedure for use of on-board Weather Radar
    ET provided its SOP and Boeing procedure for the operation of the weather radar during departure. The procedure will be addressed during the analysis phase.

    OTHER POINTS
    Our investigation pointed out that when an aircraft fails, it is a crucial part of the research to look at timely Airworthiness Directives (issued before and after) on the type of plane involved and indeed, this has become part of the ongoing research:

    1.16.4.1 Removal and Analysis of the Trim Tab section:
    ADs were issued (Emergency AD, AD 2010-09-05, AD 2010-17-19) by the FAA respectively on March and August 2010 regarding trim tab control mechanism and this airplane (with serial number 29935) was found affected by these ADs.
    Therefore, and in accordance with the Airworthiness Group recommendation, the Investigation Committee decided the removal of the trim tab control mechanism for further test and research.

    This is not the final report. The final report is due out this summer. We are looking forward to seeing if it answers some of our questions.

    The Official Report

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    NTSB SAFETY RECOMMENDATION

    National Transportation Safety Board
    Washington, DC 20594

    July 7, 2011
    http://www.ntsb.gov/doclib/recletters/2011/A-11-056-059.pdf
    The National Transportation Safety Board makes the following recommendations to the Airborne Law Enforcement Association:

    Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)

    Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)

    Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)

    Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-59)

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    June 30, Yemenia Flight 626

    We remember on June 2009 when 152 people died aboard a Yemenia Airlines Airbus A310-300.

    Yemenia Flight 626.

    We remember.

    The years pass and the headlines fade, but the families will never forget the loss of their loved ones, and neither should we.

    The pilot was about to land on an airstrip in the Comores Islands when ATC lost contact.

    The plane and all its passengers crashed into the ocean.

    12-year old Bahia Bakari survived the crash, rescued after thirteen hours in the ocean, clinging to debris. She was and is a miracle.

    The final report on Flight 626 concluded the crash was due to the crew’s inappropriate flight control inputs that led to an aerodynamic stall.

    Crews inappropriate flight control inputs means pilot error. In this case, the pilot error was exacerbated by a nineteen year old plane in dubious condition, bad weather conditions (winds gusting to 64 km/h 40 mph; 35 kn) and a primitive airport.

    Crashes like Yemenia should function like red lights. The only way they make sense is if when they happen, we stop and consider those who were lost, and investigate what went wrong. On behalf of safety, the aviation industry should mandate to use every atom of what is discovered to prevent future accidents. The industry in general, and the airlines in specific should make changes that will help prevent future accidents.

    Pilot error means airlines like Yemenia are still having problems training pilots. Still problems in the cockpit. Sadly, conditions still exist for more accidents like this in Yemenia’s future.

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    Yemenia Jet Engine Explodes


    Pictured: A Yemenia – Yemen Airways Boeing 737-8Q8
    Click to view full size photo at Airliners.net
    Contact photographer Andre Oferta

    What: Yemenia Boeing 737-800 en route from Sana’a to Cairo
    Where: Sana’a International Airport
    When: Dec 22m 2009
    Who: not available
    Why: About thirty minutes after taking off from Sana’a for Cairo, one of the jet’s engines exploded.

    The plane returned to Sana’a, and made a safe landing. No one aboard was reported as being injured. Passengers waited almost 3 hours for a replacement flight.

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