Flugunfall 04 APR 2011 einer Canadair CL-600-2B19 Regional Jet CRJ-100ER 4L-GAE - Kinshasa-N'Djili Airport (FIH)
ASN logo
 

Status:Accident investigation report completed and information captured
Datum:Montag 4 April 2011
Zeit:13:56
Flugzeugtyp:Silhouette image of generic CRJ1 model; specific model in this crash may look slightly different
Canadair CL-600-2B19 Regional Jet CRJ-100ER
Betrieben durch:United Nations - UN
Gemietet von :Georgian Airways
Kennzeichen: 4L-GAE
Werknummer: 7070
Baujahr: 1995
Triebwerk: 2 General Electric CF34-3A1
Besatzung:Todesopfer: 4 / Insassen: 4
Fluggäste:Todesopfer: 28 / Insassen: 29
Gesamt:Todesopfer: 32 / Insassen: 33
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:Kinshasa-N'Djili Airport (FIH) (   Kongo/Kinshasa)
Flugphase: Landung (LDG)
Betriebsart:Inländischer außerplanmäßiger Passagierflug
Flug von:Kisangani-Bangoka International Airport (FKI/FZIC), Kongo/Kinshasa
Flug nach:Kinshasa-N'Djili Airport (FIH/FZAA), Kongo/Kinshasa
Flugnummer: 834
Unfallbericht:
A CRJ-100ER passenger plane, operating on a United Nations flight, was destroyed in an accident at Kinshasa-N'Djili Airport (FIH), Democratic Republic of the Congo. The airplane carried 29 passengers and four crew members. One passenger survived the accident.
The airplane operated on behalf of the United Nations Organization Stabilization Mission in the Democratic Republic of the Congo (MONUSCO) on flight UNO834, a round trip from Kinshasa-N'Djili Airport (FIH) to Kisangani (FKI).
The aircraft took off from Kisangani for Kinshasa at 12:18. The pilot in command was the pilot flying on this leg.
At 13:31, the crew reported to Kinshasa Approach that they were over position GURUT (137 NM from Kinshasa), gave their Expected Time of Arrival Kinshasa as 13:55 and received the latest Kinshasa weather information. At the time, Kinshasa weather being reported was wind 340 degrees, 8 knots, visibility 10 km, scattered clouds at 2500 feet, Charlie Bravos (CBs) at 3000 feet, CBs in the North East and South East, Temperature 33, dew point 23, QNH 1009, trend NOSIG.
At 13:39, UNO 834 requested for descent and was cleared to descend to flight level 100. Meanwhile, on the on-board weather radar, the crew were able to notice presence of severe weather around and over Kinshasa airfield.
At 13:49, when the aircraft was about 32 NMs from Kinshasa VOR/DME, the crew again sought latest weather information from Kinshasa ATC. They were informed that Kinshasa was reporting "wind 210 degrees, 8 knots, visibility 8 KM, thunderstorm over the station, scattered cloud at 2500 feet, few Charlie Bravo 3000 feet, Charlie Bravo located north-east, south west and west, broken 12000 feet, temperature 33, dew point 23, QNH 1008, trend NOSIG". The co-pilot replied to ATC that weather was copied and read back the QNH.
At 13:50, UNO 854 was cleared for a straight-in Localizer approach for runway 24. The crew discussed options of avoiding the severe weather being displayed on their on-board weather radar by skirting around the radar returns. The aircraft approached the airfield at high speed. The indicated air speed came below 250 knots at 13:53 when the aircraft was descending through an altitude of 4630 feet and was 13 NM from threshold runway 24.
While intercepting the Localizer for runway 24, the aircraft remained to the south (left) of the Localizer path. During the execution of the Localizer Approach, the crew made a more than 15 degree heading change to fly even further away from the Localizer path when the aircraft was between 10-7 NM from runway 24.
As the aircraft came close to the airfield, the co-pilot sighted the runway on his right one o'clock position, when the aircraft was about 9.7 nautical miles from displaced threshold of runway 24. The PIC too, sighted the runway when the aircraft was about 6.4 NM away from threshold. At that stage, the aircraft speed was 210 knots, altitude was 3250 feet (or about 2252 feet above ground level) and the aircraft was in clean configuration. The crew decided to continue their Approach. The captain disengaged the autopilot, turned towards the runway and gave instructions to co-pilot to configure the aircraft for landing. The crew managed to regain Localizer path and align the aircraft to the runway by the time they were 2 NM from the threshold.
At around this time, Kinshasa airfield was affected by a squall line. As the aircraft came on short finals, it encountered rain. By this stage, the aircraft was below the Minimum Descent Altitude (MDA) for Localizer Approach for runway 24. MDA for Localizer Approach for Runway 24 is 1470 feet or 472 feet Above Ground Level (AGL). The crew switched on wind shield wipers. As they descended further to about 224 feet AGL and runway was not in sight, the crew decided to carry out a go around. During the process of go around, a positive rate of climb was established with appropriate airspeed.
While climbing through an altitude of 1395 feet (or 397 feet AGL); the aircraft encountered a severe weather phenomenon (probably a microburst). The wind shear warning came on. The aircraft pitched significantly nose down (from about 4-5 degrees nose up attitude to 7 degrees nose down attitude) in a very short period of time. The aircraft rapidly lost height. Before the crew could react to the pitch down and recover from the steep descent, the aircraft impacted the terrain. The airplane broke up and the main wreckage came to rest upside down.

Probable Cause:

Probable cause of the Accident:

The most probable cause of the accident was the aircraft's encounter with a severe Microburst like weather phenomenon at a very low altitude during the process of Go Around. The severe vertical
gust/downdraft caused a significant and sudden pitch change to the aircraft which resulted in a considerable loss of height. Being at very low altitude, recovery from such a disturbance was not possible.
The possibility of a somatogravic illusion caused Loss Of Control (LOC) as the primary cause of the accident, was also discussed by the investigation team. This was ruled out based on available evidence which showed that during the Go Around, the crew had initiated the climb at 1256 32 and had thereafter, maintained a climbing attitude for the next 12 seconds. At 1256 44, the aircraft experienced a sudden and steep nose down attitude change without a corresponding control input by the crew (as shown by FDR), Hence, Somatogravic Illusion caused Loss of Control was ruled out as a cause of accident.

Probable contributing factors:
1. The inappropriate decision of the crew to continue the approach, in face of extremely inclement weather being displayed on their weather radar, was probably the principle contributing factor responsible for the accident.
2. Lack of adequate supervision by the Operator to ensure that its crew complied with established procedures including weather avoidance procedures and Stabilized Approach criteria, was a probable contributing factor.
3. Inadequacy of Georgian Airways Training program for upgrade to Captain was a probable contributing Factor.
4. Lack of effective oversight of Georgian Airways by Georgian CAA was a probable contributing factor.
5. Lack of appropriate equipment at Kinshasa airport for identification and tracking of adverse weather phenomenon, resulting in failure by ATC to provide appropriate early warning to the aircraft, was probably a contributing factor.
6. ATC not declaring the airfield closed when visibility dropped below Minima was a probable contributory factor.

Accident investigation:

cover
Investigating agency: IAAI DRC
Status: Investigation completed
Duration: 2 years and 10 months
Accident number: Final report
Download report: Final report

Informationsquelle:
» AFP
» Radio Okapi
» MONUSCO statement
» SKYbrary 


Fotos

photo of Canadair-CRJ-100ER-4L-GAE
accident date: 04-04-2011
type: Canadair CRJ-100ER
registration: 4L-GAE
 

Video, social media

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Kisangani-Bangoka International Airport to Kinshasa-N'Djili Airport as the crow flies is 1219 km (762 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
languages: languages

Share

CRJ100

  • 1054+ built
  • 11th loss
  • 7th Fataler Unfall
  • 3rd worst accident
» safety profile

 Kongo/Kinshasa
  • 12th worst accident (Zu diesem Zeitpunkt)
  • 13th worst accident (Momentan)
» safety profile

The Aviation Safety Network is an exclusive service provided by:
Quick Links:

CONNECT WITH US: FSF on social media FSF Facebook FSF Twitter FSF Youtube FSF LinkedIn FSF Instagram

©2024 Flight Safety Foundation

1920 Ballenger Av, 4th Fl.
Alexandria, Virginia 22314
www.FlightSafety.org