Crash of a Piper PA-31-350 Navajo Chieftain in Nome

Date & Time: Feb 19, 2009 at 1812 LT
Operator:
Registration:
N41185
Survivors:
Yes
Schedule:
Brevig Mission – Nome
MSN:
31-8553001
YOM:
1985
Flight number:
FTA8218
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
24850
Captain / Total hours on type:
7500.00
Aircraft flight hours:
10928
Circumstances:
The scheduled commuter flight was about 10 miles north of the destination airport, operating under a special visual-flight-rules clearance, and descending for landing in instrument meteorological conditions. According to the pilot he started a gradual descent over an area of featureless, snow-covered, down-sloping terrain in whiteout and flat light conditions. During the descent a localized snow shower momentarily reduced the pilot’s forward visibility and he was unable to discern any terrain features. The airplane collided with terrain in an all-white snow/ice field and sustained substantial damage. At the time of the accident the destination airport was reporting visibility of 1.5 statute miles in light snow and mist, broken layers at 900 and 1,600 feet, and 3,200 feet overcast, with a temperature and dew point of 25 degrees Fahrenheit. The pilot reported that there were no pre accident mechanical problems with the airplane and that the accident could have been avoided if the flight had been operated under an instrument-flight-rules flight plan.
Probable cause:
The pilot's continued flight into adverse weather and his failure to maintain clearance from terrain while on approach in flat light conditions.
Final Report:

Crash of a Piper PA-31 Navajo Chieftain in Darwin

Date & Time: Feb 6, 2009 at 0840 LT
Operator:
Registration:
VH-TFX
Flight Phase:
Survivors:
Yes
Schedule:
Darwin – Maningrida
MSN:
31-8152143
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Darwin Airport, while in initial climb, one of the engine failed. The pilot declared an emergency and elected to return but eventually attempted to ditch the aircraft that came to rest in shallow water about 200 metres offshore. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-31-350 Navajo Chieftain in Bathurst: 4 killed

Date & Time: Nov 7, 2008 at 2024 LT
Registration:
VH-OPC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Melbourne – Bathurst – Port Macquarie
MSN:
31-7952082
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2061
Aircraft flight hours:
11000
Circumstances:
On 7 November 2008, a Piper Aircraft Corp. PA-31-350 Chieftain, registered VH-OPC, was being operated on a private flight under the instrument flight rules (IFR) from Moorabbin Airport, Vic. to Port Macquarie via Bathurst, NSW. On board the aircraft were the owner-pilot and three passengers. The aircraft departed Moorabbin Airport at about 1725 Eastern Daylight-saving Time and arrived at Bathurst Airport at about 1930. The pilot added 355 L of aviation gasoline (Avgas) to the aircraft from a self-service bowser and spent some time with the passengers in the airport terminal. Recorded information at Bathurst Airport indicated that, at about 2012 (12 minutes after civil twilight), the engines were started and at 2016 the aircraft was taxied for the holding point of runway 35. The aircraft was at the holding point for about 3 minutes, reportedly at high engine power. At 2020, the pilot broadcast that he was entering and backtracking runway 35 and at 2022:08 the pilot broadcast on the common traffic advisory frequency that he was departing (airborne) runway 35. At 2023:30, the pilot transmitted to air traffic control that he was airborne at Bathurst and to standby for departure details. There was no record or reports of any further radio transmissions from the pilot. At about 2024, a number of residents of Forest Grove, a settlement to the north of Bathurst Airport, heard a sudden loud noise from an aircraft at a relatively low height overhead, followed shortly after by the sound of an explosion and the glow of a fire. A witness located about 550 m to the south-west of the accident site, reported seeing two bright lights that were shining in a constant direction and ‘wobbling’. There was engine noise that was described by one witness as getting very loud and ‘rattling’ or ‘grinding’ abnormally before the aircraft crashed. At 2024:51, the first 000 telephone call was received from witnesses and shortly after, emergency services were notified. The aircraft was seriously damaged by impact forces and fire, and the four occupants were fatally injured.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving Piper Aircraft Corp. PA-31-35 Chieftain, registered VH-OPC, 3 km north of Bathurst Airport on 7 November 2008 and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The aircraft descended at a steep angle before impacting the ground at high speed, consistent with uncontrolled flight into terrain.
Other key findings:
• Based on analysis of the available information, an airworthiness issue was considered unlikely to be a contributing factor to this accident.
• The investigation was unable to establish why the aircraft collided with terrain; however, pilot spatial disorientation or pilot incapacitation could not be discounted.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in North Las Vegas: 1 killed

Date & Time: Aug 28, 2008 at 1238 LT
Operator:
Registration:
N212HB
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
North Las Vegas - Palo Alto
MSN:
31-8152072
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3195
Captain / Total hours on type:
100.00
Aircraft flight hours:
6373
Circumstances:
During climb a few minutes after takeoff, a fire erupted in the airplane's right engine compartment. About 7 miles from the departure airport, the pilot reversed course and notified the air traffic controller that he was declaring an emergency. As the pilot was proceeding back toward the departure airport witnesses observed fire beneath, and smoke trailing from, the right engine and heard boom sounds or explosions as the airplane descended. Although the pilot feathered the right engine's propeller, the airplane's descent continued. The 12-minute flight ended about 1.25 miles from the runway when the airplane impacted trees and power lines before coming to rest upside down adjacent to a private residence. A fuel-fed fire consumed the airframe and damaged nearby private residences. The airplane was owned and operated by an airplane broker that intended to have it ferried to Korea. In preparation for the overseas ferry flight, the airplane's engines were overhauled. Maintenance was also performed on various components including the engine-driven fuel pumps, turbochargers, and propellers. Nacelle fuel tanks were installed and the airplane received an annual inspection. Thereafter, the broker had a ferry pilot fly the airplane from the maintenance facility in Ohio to the pilot's Nevada-based facility, where the ferry pilot had additional maintenance performed related to the air conditioner, gear door, vacuum pump, and idle adjustment. Upon completion of this maintenance, the right engine was test run for at least 20 minutes and the airplane was returned to the ferry pilot. During the following month, the ferry pilot modified the airplane's fuel system by installing four custom-made ferry fuel tanks in the fuselage, and associated plumbing in the wings, to supplement the existing six certificated fuel tanks. The ferry pilot held an airframe and powerplant mechanic certificate with inspection authorization. He reinspected the airplane, purportedly in accordance with the Piper Aircraft Company's annual inspection protocol, signed the maintenance logbook, and requested Federal Aviation Administration (FAA) approval for his ferry flight. The FAA reported that it did not process the first ferry pilot's ferry permit application because of issues related to the applicant's forms and the FAA inspector's workload. The airplane broker discharged the pilot and contracted with a new ferry pilot (the accident pilot) to immediately pick up the airplane in Nevada and fly it to California, the second ferry pilot's base. The contract specified that the airplane be airworthy. In California, the accident pilot planned to complete any necessary modifications, acquire FAA approval, and then ferry the airplane overseas. The discharged ferry pilot stated to the National Transportation Safety Board (NTSB) investigator that none of his airplane modifications had involved maintenance in the right engine compartment. He also stated that when he presented the airplane to the replacement ferry pilot (at most 3 hours before takeoff) he told him that fuel lines and fittings in the wings related to the ferry tanks needed to be disconnected prior to flight. During the Safety Board's examination of the airplane, physical evidence was found indicating that the custom-made ferry tank plumbing in the wings had not been disconnected. The airplane wreckage was examined by the NTSB investigation team while on scene and following its recovery. Regarding both engines, no evidence was found of any internal engine component malfunction. Notably, the localized area surrounding and including the right engine-driven fuel pump and its outlet port had sustained significantly greater fire damage than was observed elsewhere. According to the Lycoming engine participant, the damage was consistent with a fuel-fed fire originating in this vicinity, which may have resulted from the engine's fuel supply line "B" nut being loose, a failed fuel line, or an engine-driven fuel pumprelated leak. The fuel supply line and its connecting components were not located. The engine-driven fuel pump was subsequently examined by staff from the NTSB's Materials Laboratory. Noted evidence consisted of globules of resolidified metal and areas of missing material consistent with the pump having been engulfed in fire. The staff also examined the airplane. Evidence was found indicating that the fire's area of origin was not within the wings or fuselage, but rather emanated from a localized area within the right engine compartment, where the engine-driven fuel pump and its fuel supply line and fittings were located. However, due to the extensive pre- and post-impact fires, the point of origin and the initiating event that precipitated the fuel leak could not be ascertained. The airplane's "Pilot Operator's Handbook" (POH), provides the procedures for responding to an in-flight fire and securing an engine. It also provides single-engine climb performance data. The POH indicates that the pilot should move the firewall fuel shutoff valve of the affected engine to the "off" position, feather the propeller, close the engine's cowl flaps to reduce drag, turn off the magneto switches, turn off the emergency fuel pump switch and the fuel selector, and pull out the fuel boost pump circuit breaker. It further notes that unless the boost pump's circuit breaker is pulled, the pump will continuously operate. During the wreckage examination, the Safety Board investigators found evidence indicating that the right engine's propeller was feathered. However, contrary to the POH's guidance, the right engine's firewall fuel shutoff valve was not in the "off" position, the cowl flaps were open, the magneto switches were on, the emergency fuel pump switches and the fuel selector were on, and the landing gear was down. Due to fire damage, the position of the fuel boost pump circuit breaker could not be ascertained. Calculations based upon POH data indicate that an undamaged and appropriately configured airplane flying on one engine should have had the capability to climb between 100 and 200 feet per minute and, at a minimum, maintain altitude. Recorded Mode C altitude data indicates that during the last 5 minutes of flight, the airplane descended while slowing about 16 knots below the speed required to maintain altitude.
Probable cause:
A loss of power in the right engine due to an in-flight fuel-fed fire in the right engine compartment that, while the exact origin could not be determined, was likely related to the right engine-driven fuel pump, its fuel supply line, or fitting. Contributing to the accident was the pilot's failure to adhere to the POH's procedures for responding to the fire and configuring the airplane to reduce aerodynamic drag.
Final Report:

Crash of A Piper PA-31-350 in Winterveld

Date & Time: May 7, 2008
Registration:
ZS-KKR
Flight Type:
Survivors:
Yes
MSN:
31-8052183
YOM:
1980
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing in Winterveld, the aircraft (a Panther III version) hit a rock on the ground. On impact, the right main gear was torn off. The aircraft veered to the right and came to rest with its right wing severely damaged. Nobody was injured but the aircraft was damaged beyond repair.
Probable cause:
Hit a rock on the ground after landing.

Crash of a Piper PA-31-350 Navajo Chieftain off Kodiak: 6 killed

Date & Time: Jan 5, 2008 at 1343 LT
Operator:
Registration:
N509FN
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Homer
MSN:
31-7952162
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
9437
Captain / Total hours on type:
400.00
Aircraft flight hours:
13130
Circumstances:
The airline transport pilot and nine passengers were departing in a twin-engine airplane on a 14 Code of Federal Regulations Part 135 air taxi flight from a runway adjacent to an ocean bay. According to the air traffic control tower specialist on duty, the airplane became airborne about midway down the runway. As it approached the end of the runway, the pilot said he needed to return to the airport, but gave no reason. The specialist cleared the airplane to land on any runway. As the airplane began a right turn, it rolled sharply to the right and began a rapid, nose- and right-wing-low descent. The airplane crashed about 200 yards offshore and the fragmented wreckage sank in the 10-foot-deep water. Survivors were rescued by a private float plane. A passenger reported that the airplane's nose baggage door partially opened just after takeoff, and fully opened into a locked position when the pilot initiated a right turn towards the airport. The nose baggage door is mounted on the left side of the nose, just forward of the pilot's windscreen. When the door is opened, it swings upward, and is held open by a latching device. To lock the baggage door, the handle is placed in the closed position and the handle is then locked by rotating a key lock, engaging a locking cam. With the locking cam in the locked position, removal of the key prevents the locking cam from moving. The original equipment key lock is designed so the key can only be removed when the locking cam is engaged. Investigation revealed that the original key lock on the airplane's forward baggage door had been replaced with an unapproved thumb-latch device. A Safety Board materials engineer's examination revealed evidence that a plastic guard inside the baggage compartment, which is designed to protect the door's locking mechanism from baggage/cargo, appeared not to be installed at the time of the accident. The airplane manufacturer's only required inspection of the latching system was a visual inspection every 100 hours of service. Additionally, the mechanical components of the forward baggage door latch mechanism were considered "on condition" items, with no predetermined life-limit. On May 29, 2008, the Federal Aviation Administration issued a safety alert for operators (SAFO 08013), recommending a visual inspection of the baggage door latches and locks, additional training of flight and ground crews, and the removal of unapproved lock devices. In July 2008, Piper Aircraft issued a mandatory service bulletin (SB 1194, later 1194A), requiring the installation of a key lock device, mandatory recurring inspection intervals, life-limits on safety-critical parts of forward baggage door components, and the installation of a placard on the forward baggage door with instructions for closing and locking the door to preclude an in-flight opening. Post accident inspection discovered no mechanical discrepancies with the airplane other than the baggage door latch. The airplane manufacturer's pilot operating handbook did not contain emergency procedures for an in-flight opening of the nose baggage door, nor did the operator's pilot training program include instruction on the proper operation of the nose baggage door or procedures to follow in case of an in-flight opening of the door. Absent findings of any other mechanical issues, it is likely the door locking mechanism was not fully engaged and/or the baggage shifted during takeoff, and contacted the exposed internal latching mechanism, allowing the cargo door to open. With the airplane operating at a low airspeed and altitude, the open baggage door would have incurred additional aerodynamic drag and further reduced the airspeed. The pilot's immediate turn towards the airport, with the now fully open baggage door, likely resulted in a sudden increase in drag, with a substantive decrease in airspeed, and an aerodynamic stall.
Probable cause:
The failure of company maintenance personnel to ensure that the airplane's nose baggage door latching mechanism was properly configured and maintained, resulting in an inadvertent opening of the nose baggage door in flight. Contributing to the accident were the lack of information and guidance available to the operator and pilot regarding procedures to follow should a baggage door open in flight and an inadvertent aerodynamic stall.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Moadamiyeh: 3 killed

Date & Time: Oct 7, 2007
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Damascus - Damascus
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a local training flight in Damascus. Apparently, the pilots encountered technical problems and attempted an emergency landing in an olive grove when the aircraft crashed against a wall. All three occupants were killed.

Crash of a Piper PA-31-350 Navajo Chieftain in Orlando

Date & Time: Jul 11, 2007 at 1215 LT
Operator:
Registration:
N105GC
Flight Type:
Survivors:
Yes
Schedule:
Melbourne - Orlando
MSN:
31-7652130
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13000
Captain / Total hours on type:
200.00
Circumstances:
The airplane had undergone routine maintenance, and was returned to service on the day prior to the incident flight. The mechanics who performed the maintenance did not secure the right engine cowling using the procedure outlined in the airplane's maintenance manual. The mechanic who had been working on the outboard side of the right engine could not remember if he had fastened the three primary outboard cowl fasteners before returning the airplane to service. During the first flight following the maintenance, the right engine's top cowling departed the airplane. The pilot secured the right engine, but the airplane was unable to maintain altitude, so he then identified a forced landing site. The airplane did not have a sufficient glidepath to clear a tree line and buildings, so he landed the airplane in a clear area about 1,500 yards short of the intended landing area. The airplane came to rest in a field of scrub brush, and about 5 minutes after the pilot deplaned, the grass under the left engine ignited. The subsequent brush fire consumed the airplane. Examination of the right engine cowling revealed that the outboard latching fasteners were set to the "open" position. When asked about the security of the cowling during the preflight inspection, the pilot stated that he "just missed it."
Probable cause:
The mechanic's failure to secure the right engine cowling fasteners. Contributing to the incident was the pilot's inadequate preflight inspection.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Matambwe

Date & Time: Jun 30, 2007 at 1430 LT
Operator:
Registration:
5H-WAY
Survivors:
Yes
Schedule:
Dar es Salaam – Matambwe
MSN:
31-7305096
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Dar es Salaam Airport on a charter flight to Matambwe, in the Selous Game Reserve, carrying five Finnish tourists and one pilot. Upon landing at Matambwe Airstrip, the pilot decided to initiate a go-around procedure when the aircraft collided with trees located past the runway end and crashed, bursting into flames. All six occupants were injured, two seriously. The aircraft was destroyed by fire.