Crash of a Cessna 402B off Vilanculos: 6 killed

Date & Time: Nov 18, 1997
Type of aircraft:
Registration:
ZS-JTD
Survivors:
Yes
MSN:
402B-1240
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
On approach to Vilanculos Airport, the pilot encountered bad weather conditions with limited visibility due to heavy rain falls. On final, the twin engine aircraft crashed in the sea few hundred metres offshore. A passenger was rescued while six other occupants were killed.

Crash of a Beechcraft B100 King Air in Jackson: 1 killed

Date & Time: Nov 13, 1997 at 1238 LT
Type of aircraft:
Registration:
N500ML
Survivors:
No
Schedule:
Muscle Shoals – Jackson
MSN:
BE-78
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3646
Captain / Total hours on type:
162.00
Aircraft flight hours:
4231
Circumstances:
During an IFR arrival, vectors were provided for an ILS runway 16L approach. While on assigned heading and altitude of 270 degrees and 3,000 feet, about 8 miles north of the final approach fix, the pilot was told to turn left to 185 degrees and maintain 2,200 feet until established on the localizer, then he was cleared for the approach. The pilot acknowledged the instructions. About 1 minute later, communication and radar contact with the airplane were lost. Eye witnesses near the accident site observed the airplane as it descended below the cloud layer. The airplane was described as being in a steep left bank with the nose down. Witnesses also stated that the engines were revving. Within seconds of the visual sighting, the airplane crashed. Examination of the airframe failed to disclose a mechanical problem. No fire or smoke was seen coming from the airplane before it crashed. The pilot did not report experiencing a problem with the airplane to the tower controller. Toxicology tests of the pilot indicated O.323 mcg/ml chlorpheniramine (a sedating antihistamine) in liver fluid and 0.073 mcg/ml chlorpheniramine in kidney fluid. Also, unspecified levels of dextromethorphan (a cough suppressant), pseudoephedrine (a decibgestabt), and phenylpropanolamine (a decongestant) were reported in kidney and liver fluids. All medications are available in over-the-counter cold remedies.
Probable cause:
The pilot's failure to maintain control of the aircraft due to spatial disorientation. A related factor was: the instrument weather conditions.
Final Report:

Crash of a Cessna 500 Citation I in Canela: 3 killed

Date & Time: Oct 31, 1997 at 1650 LT
Type of aircraft:
Operator:
Registration:
PT-LQG
Survivors:
No
Schedule:
Curitiba - Canela
MSN:
500-0271
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The approach to Canela Airport was completed in marginal weather conditions with rain falls and a visibility estimated to be 1,500 - 2,000 metres. The landing was completed with a tail wind component of 15-20 knots and the aircraft landed too far down a wet runway which is 1,250 metres long. Unable to stop within the remaining distance, the aircraft overran, went down an embankment, crossed a road and came to rest against houses, bursting into flames. The aircraft was destroyed and all three occupants were killed.
Probable cause:
The following findings were reported:
- Wrong approach configuration,
- Marginal weather conditions with limited visibility due to rain falls,
- The crew completed the landing with a tailwind component of 15-20 knots,
- The runway surface was wet,
- The runway length was 1,250 metres only,
- The aircraft landed too far down the runway, reducing the landing distance available,
- The braking action was poor because the runway surface was wet,
- The crew failed to initiate a go-around procedure.

Crash of a Cessna 425 Conquest I in Perkasie

Date & Time: Aug 17, 1997 at 1820 LT
Type of aircraft:
Operator:
Registration:
N1224S
Flight Phase:
Survivors:
Yes
Schedule:
Niagara Falls – Rancocas
MSN:
425-0211
YOM:
1984
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3013
Captain / Total hours on type:
373.00
Aircraft flight hours:
3836
Circumstances:
During preflight, the pilot noticed a discrepancy between his requested fuel load and what the fuel gauges indicated. He decided the right fuel quantity gauge was accurate and the left fuel quantity gauge was inaccurate, and started a multiple leg flight. Based on the right fuel gauge indication at an away airport, the pilot elected to not refuel prior to starting his return flight. About 50 miles from the destination, the left and right low fuel quantity lights illuminated, and the right fuel gauge indicated 390 pounds of fuel onboard. The pilot elected to continue to his destination. A few minutes later, both engines lost power. A forced landing was made in an open school field. Before coming to rest, the left wing struck a football training device, and the outboard 4 feet of the wing was separated from the airplane. Post accident investigation revealed, both fuel tanks, collector tanks, fuel lines, and filters were empty. When electric power was applied, the left fuel gauge indicated '0' and the right fuel gauge indicated 290 pounds of fuel remaining. The pilot reported that he should have monitored his fuel supply closer and landed at the first sign of any inconsistencies in fuel quantity readings.
Probable cause:
The pilot's inadequate preflight, by failing to verify the fuel supply, which led to subsequent fuel exhaustion and loss of engine power. A related factor was: the inaccurate fuel quantity gauge.
Final Report:

Crash of a Cessna 402 in Semarang

Date & Time: Aug 14, 1997
Type of aircraft:
Operator:
Registration:
PK-BBI
Survivors:
Yes
Site:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Semarang-Ahmad Yani Airport runway 31, the twin engine aircraft went out of control and crashed in the district of Bongsari, less than 3 km from the airport. All seven occupants were injured.

Crash of a Cessna 421A Golden Eagle I in Shobdon: 3 killed

Date & Time: Aug 3, 1997 at 1521 LT
Type of aircraft:
Operator:
Registration:
G-BKNA
Survivors:
Yes
Schedule:
Elstree - Shobdon
MSN:
421A-0097
YOM:
1968
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2386
Circumstances:
The aircraft was on a private flight from Elstree to Shobdon in Herefordshire. The meteorological forecast indicated that a warm front was approaching Southern England from the south-west and conditions were generally deteriorating. The visibility on departure from Elstree at 1437 hrs was greater than 10 km with a broken cloud base at 2,500 feet. When the aircraft arrived at Shobdon the visibility was estimated to be 3 to 4 km in light drizzle with a cloud base at approximately 1,200 feet, and the surface wind was 090_/5 kt. The first radio contact between the aircraft and Shobdon was made at about 1502 hrs when the pilot called to say that he was inbound from Elstree. In response to this call he was passed the airfield details. The pilot later called when approaching Leominster and subsequently called downwind for Runway 09 which has a right-hand circuit. The operator of the ground to air radio facility at Shobdon saw the aircraft on the downwind leg abeam the tower at what appeared to be a normal circuit height. He did not observe the aircraft downwind but shortly afterward she heard a brief and indecipherable radio transmission which sounded like a scream. This same transmission was heard by an aircraft enthusiast who was monitoring the radio transmissions on his 'airband' radio. The radio operator repeatedly attempted to make contact with the aircraft but to no avail and so he instructed an aircraft refueller to inform the emergency services that an aircraft had crashed. Analysis of recorded radar data from the radar head at Clee Hill,Shropshire, indicates that the aircraft joined the downwind leg from the east at a height of 1,100 feet. This radar data shows that the aircraft then followed a normal ground track until towards the end of the downwind leg when there was an alteration of track to the left of about 20_ before the aircraft entered a right turn onto the base leg. At the same time as the aircraft altered track to the left it began a slow descent, at about 350 ft/min, from 1,100 feet to 600 feet, at which stage it disappeared below radar coverage. The average ground speed on the downwind leg was 112kt and this reduced to 100 kt as the aircraft descended. Two witnesses saw the aircraft in a position that equates to the base leg. The witness to the east of the aircraft track first heard the sound of an aircraft engine that was unusually loud and then saw the aircraft at an estimated height of 150 to 200 feet, it was descending slowly with the wings level. A loud "cough"from one of the engines was heard "as if it had backfired"followed by a puff of white smoke and then the sound of an engine increasing in RPM. The wings were then seen to rock from side to side as the aircraft went out of sight. The second witness,to the west of the aircraft track, described the aircraft flying very low, between 50 and 100 feet, and slowly descending. He saw that the wings were "wavering", the left wing then suddenly dropped until it achieved a bank angle of about 90_ at which stage the nose dropped and the aircraft disappeared behind some low trees and was heard to hit the ground. Some local farmers immediately went to the crash site. Initially there was no fire or smoke, but a small fire soon developed in the area of the right wing and this was quickly extinguished by the farmers.
Probable cause:
Examination of the engines showed that they had both been mechanically and electrically capable of running, however, at impact the left engine was stationary. It was also likely that there was very little fuel onboard the aircraft at the time of the accident. It is therefore probable that mismanagement of the fuel system caused the left engine to stop. The eye witness accounts are consistent with the behaviour of a twin engine aircraft that has suffered a failure of one engine and is flown below its minimum control speed for flight on one engine. With a low power setting on the right (live) engine the speed was allowed to reduce further until the left wing stalled. There was then insufficient height available to regain control of the aircraft
Final Report:

Crash of a Rockwell Grand Commander 690A in Garuva: 5 killed

Date & Time: Jun 7, 1997 at 1000 LT
Operator:
Registration:
PT-OFG
Survivors:
No
Schedule:
Curitiba - Joinville
MSN:
690-11274
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1102
Captain / Total hours on type:
525.00
Copilot / Total flying hours:
578
Copilot / Total hours on type:
398
Circumstances:
While approaching Joinville Airport at an altitude of 7,000 feet, the crew canceled his IFR flight plan and continued under VFR mode. Few minutes later, the crew encountered atmospheric turbulences and lost control of the aircraft that crashed near Gavura, about 24 km northwest of Joinville Airport. The aircraft was destroyed and all five occupants were killed.
Probable cause:
The following factors were identified:
- Weather conditions were marginal with atmospheric turbulences,
- Loss of control after the captain exercised poor judgment about weather conditions and demonstrated overconfidence as he was trying to beat his speed record on this leg,
- Lack of administrative, technical and operational crew surveillance by the operator,
- Poor crew coordination,
- Excessive speed on descent,
- The radiosonde from the meteorology surveillance center based in Curitiba was unserviceable.
Final Report:

Crash of a Beechcraft B90 King Air in Pesqueria

Date & Time: Mar 7, 1997 at 1210 LT
Type of aircraft:
Registration:
XB-CIO
Flight Phase:
Survivors:
Yes
Schedule:
Saltillo - Monterrey
MSN:
LJ-387
YOM:
1969
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While in cruising altitude on a flight from Saltillo to Monterrey, both engines failed simultaneously. The pilot was able to reduce his altitude and attempted an emergency landing in an open field located near Pesqueria. Both occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Double engine failure in flight caused by a fuel exhaustion.

Crash of a Cessna 500 Citation I near La Felisa: 2 killed

Date & Time: Mar 7, 1997 at 0934 LT
Type of aircraft:
Registration:
HK-3885
Flight Phase:
Survivors:
No
Site:
Schedule:
Pereira - Medellín
MSN:
500-0135
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3048
Copilot / Total flying hours:
173
Aircraft flight hours:
6274
Circumstances:
After takeoff from Pereira-Matecaña Airport, while climbing, the copilot declared an emergency and reported problems. Shortly later, the aircraft entered an uncontrolled descent and crashed near La Felisa. The aircraft was destroyed and both pilots were killed.
Probable cause:
In-flight braking and subsequent separation of both wing tips due to positive wing loading imposed by the unqualified crew exceeding the structural limit stipulated by the manufacturer.
Final Report:

Crash of a Beechcraft 200 Super King Air in Salt Lake City: 1 killed

Date & Time: Mar 2, 1997 at 1913 LT
Registration:
N117WM
Survivors:
Yes
Schedule:
Las Vegas - Salt Lake City
MSN:
BB-662
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
8172
Captain / Total hours on type:
1841.00
Aircraft flight hours:
4692
Circumstances:
The flight was on a coupled instrument landing system (ILS) approach with 1/2 mile visibility in snow showers. Three successive fixes on the localizer are defined by distance measuring equipment (DME) paired with the ILS; prior to the ILS DME commissioning 6 months before the accident, the DME fixes were defined by a VORTAC 4.7 nautical miles past the ILS DME. The aircraft was 800 feet high at the first fix and 1,500 feet high at the second, but approximately on altitude 4.7 nautical miles past the first and second fixes, respectively. It passed the outer marker 900 feet high and captured the glide slope from above about 1.8 nautical miles from the threshold, 500 feet above decision height (DH) and 700 feet above touchdown. The aircraft was on glide slope for 28 seconds, during which time its speed decayed to stall speed; it then dropped below glide slope and crashed 1.3 nautical miles short of the threshold. The pilot's FLT DIR DME-1/ DME-2 switch, which control the DME display on the pilot's horizontal situation indicator (HSI), was found set to DME-2; the NAV-2 radio was set to the VORTAC frequency. Up to 800 feet may be required for stall recovery.
Probable cause:
The pilot's failure to maintain adequate airspeed on the ILS approach, resulting in a stall. Factors included: low visibility; the pilot's selection of the improper DME for the approach; his resulting failure to attain the proper descent profile for the approach; and insufficient altitude available for stall recovery.
Final Report: