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  • 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.)
  • WW24, vicinity Norfolk Island South Pacific, 2009 (Synopsis: 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.)
  • B744, vicinity Bishkek Kyrgyzstan, 2017 (Synopsis: On 16 January 2017, a Boeing 747-400F failed to successfully complete a night auto-ILS Cat 2 approach at Bishkek and the aircraft crashed and caught fire killing its occupants and 35 people on the ground and seriously injuring 36 others. The Investigation found that the flight crew had comprehensively failed to monitor the achieved approach flight path and, after capturing and flying down the false upper ILS GS lobe, had then failed to promptly initiate a go around at the applicable decision altitude. The fact that an automatic ILS approach could continue even on a false glideslope was noted.)
  • AT76, en route, west-southwest of Sydney Australia, 2014 (Synopsis: On 20 February 2014, the mishandling of an ATR 72-600 during descent to Sydney involving opposite control inputs caused an elevator disconnect and a serious cabin crew injury. After recovery of control, the flight was without further event. Post flight inspection did not discover serious structural damage caused to the aircraft and it remained in service for a further five days. The complex Investigation took over five years and examined both the seriously flawed flight crew performance and the serious continued airworthiness failures. Despite extensive safety action in the meantime, the concluding report still made five type airworthiness-related safety recommendations.)
  • B738, Rostov-on-Don Russia, 2016 (Synopsis: On 19 March 2016, a Boeing 737-800 making a second night ILS approach to Rostov-on-Don failed to complete a go around commenced after becoming unstable in turbulent conditions and crashed at high speed within the airport perimeter killing all 62 people on board. The Investigation concluded that the Captain had lost spatial awareness and then failed to configure the aircraft correctly or control its flightpath as intended and that although the First Officer had recognised this, he had tried to coach the Captain rather than take over. It was noted that the flight up to this point had been conducted normally.)