Crash of a Rockwell Grand Commander 690 in Soto la Marina: 1 killed

Date & Time: Sep 16, 2003 at 1430 LT
Registration:
N302WB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Soto La Marina - Laredo
MSN:
690-11003
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On September 16, 2003, at 1430 central daylight time, an Aero Commander 690 twin-engine airplane, N302WB was destroyed upon impact with trees and terrain while attempting a takeoff from an airstrip near Soto La Marina, in the State of Tamaulipas, in the Republic of Mexico. The commercial pilot, sole occupant of the airplane, was fatally injured. The airplane was registered to the QEAT-4 LLC., in Naples, Florida, and was being operated by the MGS Corporation of Laredo, Texas. Visual meteorological conditions prevailed for the business flight for which no flight plan was filed. The flight's destination was reported to be Laredo, Texas. Local authorities reported that the turboprop powered airplane, serial number 11003, had previously sustained some damage to the nose landing gear and the owner had replaced the nose landing gear prior to attempting to depart from the airstrip.

Crash of a Cessna 551 Citation II/SP in Sorocaba: 1 killed

Date & Time: Jul 23, 2003 at 0840 LT
Type of aircraft:
Operator:
Registration:
PT-LME
Flight Type:
Survivors:
Yes
Schedule:
Lins - Sorocaba
MSN:
551-0023
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3920
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
90
Aircraft flight hours:
8761
Circumstances:
The aircraft departed Lins Airport on a ferry flight to Sorocaba with two pilots on one passenger (the owner) on board. The aircraft was transferred to Sorocaba Airport for maintenance purposes. While descending, the crew was informed that runway 36 was in use and that three small aircraft were completing local training in the circuit. In good weather conditions, the captain decided to complete a straight-in approach to runway 18. After touchdown, the aircraft was unable to stop within the remaining distance. It overran, crossed a road and came to rest into a ravine. The passenger escaped uninjured, the copilot was seriously injured and the captain was killed. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the crew who completed an unstabilized approach and landed too far down the runway (about a half way down) at an excessive speed. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were identified:
- The crew did not make any approach briefing,
- The crew failed to follow the approach checklist,
- The aircraft had deficiencies in maintenance, particularly with regard to the brakes systems,
- The techlogs were out of date,
- Maintenance was periodic but insufficient,
- Although the runway 36 was in use, the captain preferred to land on runway 18,
- The aircraft was unstable on short final and landed too far down the runway, reducing the landing distance available,
- The aircraft' speed upon landing was excessive, preventing the reverse thrust systems to be activated,
- The captain took over control and activated the reverse thrust system on the right engine only,
- Poor crew coordination,
- The crew was operating in a conflict environment after touchdown,
- Poor judgment of the situation,
- Poor flight planning,
- Lack of crew discipline.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Lorain

Date & Time: May 15, 2003 at 1710 LT
Type of aircraft:
Operator:
Registration:
N208AD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lorain - Anderson
MSN:
208B-0063
YOM:
1987
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1500.00
Aircraft flight hours:
12059
Circumstances:
The pilot departed in a Cessna 208B, and shortly after takeoff, he experienced a power loss. He set up for a forced landing and during the ground roll, the nose wheel sunk into the soft terrain and the airplane nosed over. Fuel was found in both wings; however, the fuel line between the fuel selector and the engine contained only trace amounts of fuel. One fuel selector was found in the OFF position, and the other fuel selector was mid-range between the OFF and ON positions. The airplane was equipped with an annunciator warning light and horn to warn if either fuel selector was turned off. The annunciator was popped out and did not make contact with the annunciator panel. The warning horn was checked and found to be inoperative, and the electrical circuitry leading to the horn was checked and found to be operative. The engine was test run with no problems noted. According to the Pilot's Operating Handbook, the position of the fuel selectors are to be checked three times before takeoff: including cabin preflight, before engine start, and before takeoff. The pilot reported that he departed with both fuel selectors on and had not touched them when the power loss occurred. A representative of Cessna Aircraft Company reported that there was sufficient fuel forward of the fuel selector valves to takeoff and fly for a few miles prior to experiencing fuel exhaustion.
Probable cause:
The pilot's failure to verify the position of the fuel selectors prior to takeoff, which resulted in a power loss due to fuel starvation. A factor was the failure of the fuel selector warning horn.
Final Report:

Crash of a Fletcher FU-24-101 in Douglas: 2 killed

Date & Time: Apr 4, 2003 at 1830 LT
Type of aircraft:
Operator:
Registration:
ZK-LTF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stratford - Stratford
MSN:
200
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1438
Captain / Total hours on type:
340.00
Aircraft flight hours:
5332
Circumstances:
The pilot had arranged to topdress properties for three clients, one of whom had three separate blocks to be treated. He departed from Stratford Aerodrome at 0653 hours in ZK-LTF for the first airstrip, located some 7 km to the north-east. After an initial reconnaissance flight, he began topdressing at 0722, and finished this block at 1034 hours. Via brief landings at Stratford and another airstrip 11 km to the north, he positioned the aircraft to a strip near Huiroa. The remainder of the day’s work was carried out from this strip. Four blocks were treated from this location: the first was 8 km to the north-west of the strip, the second immediately to the north, the third some 3 km west and the last 4.5 km to the south, adjacent to the Strathmore Saddle. A reconnaissance of the fourth block was flown at 1518, but actual spreading on this property was not commenced until 1755 hours. Two loads of urea were spread on the fourth block between 1755 and 1812 hours, with a 12-minute pause until the final take-off at 1824. During this break, the last of the urea was loaded, the fertiliser bins secured and the loading vehicle parked. It is not known if the aircraft was refuelled at this time. The loader driver boarded the aircraft after completing his duties, the apparent intention being to accompany the pilot back to Stratford on completion of the last drop. On arrival over the property at 1825, the pilot performed one run towards the south, made a left reversal turn, spread another swath on a northerly heading, and pulled up to commence another reversal turn to the left. At some time after this pull-up, the aeroplane struck the ground heavily on a south-westerly heading, killing both occupants on impact. Later in the evening, the pilot’s wife reported the aircraft and its occupants overdue, and a ground search was commenced, initially by friends and associates. The wreckage and the bodies of the crew were found about half an hour after midnight. The accident occurred during evening civil twilight, at approximately 1830 hours NZST, adjacent to the Strathmore Saddle, at an elevation of about 530 feet.
Probable cause:
Conclusions:
- The pilot was licensed, rated and fit for the flights being undertaken.
- The aeroplane had a current Airworthiness Certificate and had been maintained in accordance with current requirements.
- No pre-accident aircraft defect was found.
- The impact was consistent with partial recovery from a dive with insufficient height to do so.
- No conclusive reason could be found for the aircraft to have been in such a situation.
- Light conditions were probably conducive to difficult height judgement.
- The pilot’s judgement may have further been eroded by fatigue and a degree of carbon monoxide absorption.
- The accident was not survivable.
Final Report:

Crash of a Rockwell Grand Commander 690B in Homerville: 2 killed

Date & Time: Mar 27, 2003 at 0113 LT
Operator:
Registration:
N53LG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mount Pleasant – Titusville
MSN:
690-11523
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3581
Captain / Total hours on type:
47.00
Aircraft flight hours:
6317
Circumstances:
The flight was in cruise flight at 27,000 feet when the airplane encountered unforecasted severe turbulence. The pilot made a "mayday" on the airplane radio to Jacksonville Center. Within several seconds the airplane accelerated from 175 knots through 300 knots ground speed and descended from 27,000 feet to 16,500 feet. The airplane disappeared from radar coverage and was located by Sheriff Department personnel 15 miles north of Homerville, Georgia, in a swampy area. Airframe components recovered from the accident site were submitted to the NTSB Materials laboratory for examination. The examinations revealed all failures were due to overload. Examination of the airframe revealed that the airframe design limits were exceeded. The pilot did not obtain a weather briefing before the flight departed.
Probable cause:
An in-flight encounter with unforecasted severe turbulence in cruise flight resulting in the design limits of the airplane being exceeded due to an overload failure of the airframe, and collision with a swampy area.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Las Primaveras

Date & Time: Mar 12, 2003 at 1940 LT
Registration:
LV-MML
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mendoza – Buenos Aires
MSN:
31-7852133
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4364
Captain / Total hours on type:
52.00
Copilot / Total flying hours:
1109
Copilot / Total hours on type:
142
Circumstances:
The twin engine airplane departed Mendoza-El Plumerillo on a ferry flight to Buenos Aires-Aeroparque-Jorge Newbury Airport with two pilots on board. After takeoff, the crew was cleared to climb to 7,000 feet then to proceed to the east via airway W9. About 20 minutes into the flight, after being cleared to descend to FL55, the crew noticed smoke in the cabin. Assuming the smoke was coming from under the panel instruments, the crew used the fire extinguisher put smoke continued to spread in the cabin. The crew informed ATC about his situation, reduced his altitude and attempted an emergency landing. The crew lowered the landing gear but completed a flapless landing in an open field. The aircraft rolled for few dozen metres before coming to a halt, bursting into flames. Both pilots evacuated safely while the aircraft was consumed by fire.
Probable cause:
A fire broke out in flight, probably in the electrical wiring, for reasons that investigations were unable to determine.
Final Report:

Crash of a Cessna 208B Grand Caravan in Kotzebue

Date & Time: Mar 2, 2003 at 1504 LT
Type of aircraft:
Operator:
Registration:
N205BA
Flight Type:
Survivors:
Yes
Schedule:
Shungnak - Kotzebue
MSN:
208B-0890
YOM:
2001
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25600
Captain / Total hours on type:
4200.00
Aircraft flight hours:
2082
Circumstances:
Prior to departing on an air taxi flight, the airline transport certificated pilot obtained a weather briefing and filed a VFR flight plan for a trip from his home base, to several remote villages, and return. The area forecast contained an AIRMET for IFR conditions and mountain obscuration due to clouds and light snow. The terminal forecast contained expected conditions that included visibilities ranging from 3 to 3/4 mile in blowing snow, a vertical visibility of 500 feet, and wind speeds from 14 to 22 knots. During the filling of the flight plan, an FAA flight service station specialist advised that VFR flight was not recommended. The pilot acknowledged the weather information and departed. When the pilot took off on the return flight from an airport 128 miles east of his home base, the pilot reported that the visibility at his base was greater than 6 miles. As he neared his home base, the visibility had decreased and other pilots in the area were requesting special VFR clearances into the Class E surface area. The pilot requested a special VFR clearance at 1441, but had to hold outside the surface area for other VFR and IFR traffic. At 1453, a METAR at the airport included a wind 080 of 26 knots, and a visibility of 1 mile in blowing snow. While holding about 7 miles north of the airport, the pilot provided a pilot report that included deteriorating weather conditions east of the airport. Once the pilot was cleared to enter the surface area at 1458, he was provided with an airport advisory that included wind conditions of 25 knots, gusting to 33 knots. While the pilot was maneuvering for the approach, a special aviation weather observation at 1501 included a wind condition of 26 knots, and a visibility of 3/4 mile in blowing snow. The pilot said he established a GPS waypoint 4 miles from the runway and descended to 1,000 feet. He continued inbound and descended to 300 feet. At 1 mile from the airport, the pilot said he looked up from the instrument panel but could not see the airport. He also stated that he was in a whiteout condition. The airplane collided with the snow-covered sea ice, about 1 mile from the approach end of the runway threshold at 1504.
Probable cause:
The pilot's continued VFR flight into instrument meteorological conditions, and his failure to maintain altitude/clearance above the ground, resulting in a collision with snow and ice covered terrain during the final approach phase of a VFR landing. Factors in the accident were whiteout conditions and snow-covered terrain.
Final Report:

Crash of a Cessna 402B off Marathon

Date & Time: Feb 20, 2003 at 1220 LT
Type of aircraft:
Registration:
N554AE
Flight Type:
Survivors:
Yes
Schedule:
Havana – Marathon – Miami
MSN:
402B-1308
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
817.00
Aircraft flight hours:
11303
Circumstances:
The fuel tanks were filled the day before the accident date, and on the day of the accident, the airplane was flown from that airport to the Miami International Airport, where the pilot picked up 2 passengers and flew uneventfully to Cuba. He performed a preflight inspection of the airplane in Cuba and noted both auxiliary fuel tanks were more than half full and both main tanks were half full. The flight departed, climbed to 8,000 feet; and was normal while in Cuban airspace. When the flight arrived at TADPO intersection, he smelled strong/fumes of fuel in the cabin. The engine instruments were OK at that time. The flight continued and when it was 10-12 miles from Marathon, he smelled something burning in the cabin like plastic material/paper; engine indications at that time were normal. He declared "PAN" three times with the controller, and shortly thereafter the right engine began missing and surging. He then observed fire on top of the right engine cowling near the louvers. He secured the right engine however the odor of fuel and fumes got worse to the point of irritating his eyes. He declared an emergency with the controller, began descending at blue line airspeed, and the fumes/odor got worse. Approximately 5 minutes after the right engine began missing and surging, the left engine began acting the same way. He secured the left engine but the propeller did not completely feather. At 400 feet he lowered full flaps and (contrary to the Pilot's Operating Handbook and FAA Approved Airplane Flight Manual) the landing gear in preparation for ditching. He intentionally stalled the airplane when it was 5-7 feet above the water, evacuated the airplane with a life vest, donned then inflated it. The airplane sank within seconds and he was rescued approximately 20 minutes later. The pilot first reported 4 months and 19 days after the accident that his passport which was in the airplane at the time of the accident had burned pages. He was repeatedly asked for a signed, dated statement that explained where it was specifically located in the airplane, and that it was not burned before the accident flight; he did not provide a statement. Examination of the airplane by FAA and NTSB revealed no evidence of an in-flight fire to any portion of the airplane, including the right engine or engine compartment area, or upper right engine cowling. Examination of the left engine revealed no evidence of preimpact failure or malfunction. The left magneto operated satisfactorily on a test bench, while the right magneto had a broken distributor block; and the electrode tang which fits in a hole of the distributor gear; no determination was made as to when the distributor block fractured or the electrode tang became bent. The left propeller blades were in the feathered position. Examination of the right engine revealed no evidence or preimpact failure or malfunction. The right hand stack assembly was fractured due to overload; no fatigue or through wall thickness erosion was noted. Both magnetos operated satisfactorily on a test bench. The right propeller was in the feathered position. An aluminum fuel line that was located in the cockpit that had been replaced the day before the accident was examined with no evidence or failure or malfunction; no fuel leakage was noted.
Probable cause:
The loss of engine power to both engines for undetermined reasons.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander in Panama: 1 killed

Date & Time: Dec 29, 2002 at 1606 LT
Type of aircraft:
Operator:
Registration:
HP-1016PS
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Bocas del Toro – Panama City
MSN:
628
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, was returning to his base at Panama City-Albrook Marcos A. Gelabert Airport after he dropped seven passengers in Bocas del Toro. En route, the twin engine aircraft was lost without trace. SAR operations were initiated but eventually suspended on January 8, 2003, as no trace of the aircraft nor the pilot was found.

Crash of a Swearingen SA227AC Metro III in Aberdeen

Date & Time: Dec 24, 2002 at 0745 LT
Type of aircraft:
Operator:
Registration:
OY-BPH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Aberdeen - Aalborg
MSN:
AC-580B
YOM:
1984
Flight number:
NFA924
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4600
Captain / Total hours on type:
2800.00
Circumstances:
At approximately 0630 hrs on 24 December 2002, the pilots arrived by car at Aberdeen Airport. With no requirement for their aircraft to transport mail on this occasion, it was decided to fly directly to their home airport in Denmark. The aircraft had been refuelled the previous day and the total fuel on board of 2,200 lb was sufficient for the flight; with no cargo on board, take-off weight was calculated as 12,000 lb (maximum take-off weight: 16,000 lb). The commander carried out an external inspection on OY-BPH while the co-pilot, who was the designated handling pilot for the flight to Denmark, submitted a flight plan. The weather at 0720 hrs was reported as follows: Surface wind 150°M/ 12 kt; visibility 2,500 metres in mist; cloud scattered 100 feet agl, overcast at 200 feet agl; air temperature +9°C; QNH 994 hPa. The runway was reported as wet and Low Visibility Procedures (LVP) had been in force at Aberdeen since 0633 hrs. OY-BPH, callsign 'Birdie Nine Two Four', was parked on Taxiway Bravo and the crew called for, and were given, start clearance at 0736 hrs by 'Ground Movement Control' on frequency 121.7 MHz. Then, following their after-start checks, the crew were cleared to taxi to 'Whiskey Five' for Runway 16 at 0740 hrs. During taxi, the crew were passed and correctly acknowledged the following clearance: "LEAVE CONTROLLED AIRSPACE CLIMBING FLIGHT LEVEL ONE FIVE FIVE SQUAWK SIX TWO FOUR ZERO". Then, at 0742 hrs as the aircraft approached 'Whiskey Five', the crew were transferred to 'Aberdeen Tower' on frequency 118.1 MHz. On the 'Tower' frequency, they were given line-up clearance for Runway 16. At 0743 hrs, the controller transmitted: "BIRDIE NINE TWO FOUR WITH A LEFT TURN DIRECT KARLI CLEAR TAKE OFF ONE SIX SURFACE WIND ONE SIX ZERO ONE TWO KNOTS". The crew correctly acknowledged this clearance. The controller watched the initial movement of the aircraft along the runway before transferring her attention to another aircraft, which was lining up. Shortly after, at 0746 hrs, she transmitted: "OY-BPH REPORT TURNING LEFT" but received no reply. About this time, a telephone message was received in the 'Tower' from a witness in front of the Terminal Building to the effect that an aircraft appeared to have crashed just south of the airfield. This witness had heard a "change in pitch" from the aircraft but had seen no flames prior to it disappearing from his sight: ATC personnel immediately activated their emergency procedures. For the reduced power take-off roll, with the flaps at ¼, the power was set by the commander. The crew considered that the performance of the aircraft was normal, with no unusual instrument indications. The calculated V1 and VR speeds (co-incident at 100 kt) were achieved and called by the commander and, at VR, the co-pilot rotated the aircraft to a pitch attitude of about 12° to 15° nose-up. As the aircraft left the ground, the co-pilot detected the aircraft 'yawing' to the right; almost immediately, he was also aware of a distinct smell of smoke. He called to the commander that he had an engine failure, called for maximum power and tried to maintain control by corrective aileron and rudder inputs. The commander felt the aircraft roll about 15° to the right and realised that there was a problem with the right (No 2) engine. He reached for both power levers and moved them forward. There were no audio or visual warnings associated with the apparent problem. The commander looked at the EGT gauges with the power levers fully forward and noted that the No 2 engine indicated about 600°C EGT, whereas the left (No 1) engine indicated greater than 650°C EGT (the normal maximum) and that its fuel 'Bypass' light was on. He retarded the No 1 power lever until the 'Bypass' light extinguished and noted the resultant EGT at about 630°C. He did not recall any other abnormal indications on the engine instruments but, later in the investigation, the commander recalled hearing a sound "like a compressor stall from the right engine". About this time, the co-pilot heard the automatic "Bank Angle" voice activate. As the aircraft continued to turn to the right, the co-pilot called that he "couldn't control the aircraft". The commander reached for and pulled No 2 engine 'Stop and Feather Control' but, almost immediately, OY-BPH struck the ground initially with the right wing. The aircraft slid along the surface of a field, through a fence and onto a road, before coming to rest. As it did so, the co-pilot was aware that the aircraft had struck a car, which was now at rest outside the right forward side of the cockpit. The co-pilot saw that the whole of the right wing was on fire and called this to the commander before evacuating out of the left door of the aircraft. As the copilot left, the commander pulled No 1 engine 'Stop and Feather Control' and activated both engine fire extinguishers before leaving the aircraft. Outside OY-BPH, the co-pilot went to the car to check if anyone was still inside; as he did so, he saw someone running away. With the intense fire and the car apparently empty, both pilots moved well away from the aircraft. At 0748 hrs, the co-pilot used his mobile phone to advise ATC of the accident and to request assistance. The local emergency services had been alerted at 0745 hrs by a member of the public, who reported a road accident; by 0753 hrs, the local fire service was on the scene. By 0754 hrs, the first AFS vehicle was on the scene and three further AFS vehicles arrived one minute later. A fifth vehicle arrived at 0800 hrs. The fire was quickly extinguished and the Fire Officer confirmed that all the aircraft and vehicle occupants had been located and that there had been no serious injuries. Following runway and taxiway inspections, the airport was re-opened at 0954 hrs.
Probable cause:
Although the investigation was hampered by the lack of FDR data, which might have provided information on engine handling and behaviour, the available evidence from the crew and the initial examination of the aircraft at the accident site, pointed to a major loss of power in the right engine. As a result of the discovery of dead birds close to the point of lift-off on the runway, and a section of braided wire found near the start of the take-off roll, consideration was given as to whether the these had been factors in the accident. The braided wire was not identified as having originated from OY-BPH. There was conclusive evidence that the left engine, which had continued to run, had ingested parts of birds, but no such evidence was found with the right engine. Nevertheless, the crew were adamant that there was a power loss from the right engine and were not conscious of any power reduction from the left engine. The technical examination of the left engine and its propeller assembly revealed evidence of damage consistent with this unit delivering a high level of power at impact. The examination of the right engine and propeller revealed all damage to be consistent with a low, or no, power condition at impact, consistent with either a genuine loss of power or as a consequence of the commander pulling the 'Stop and Feather' control immediately before impact. However, an exhaustive examination of the right engine revealed no evidence of anything that could have caused a failure. Therefore, the items found on the runway were not considered to have been causal or contributory factors in the accident. The crew's recollection of the event included a low EGT indication, at 600°C. This suggested that either the engine might have flamed out, should they have only momentarily looked at the indication as the engine was cooling down, or that the engine was operating at reduced power for an undetermined reason. Flame out could have occurred due to a number of reasons, including, for example, water contamination of the fuel. However, analysis of the bulk supply samples proved negative and, moreover, there were no reports of contaminated fuel from other operators at Aberdeen Airport. Ingestion of ice or water could also have resulted in a flame-out, although this is considered unlikely due to the conditions not being conducive to the formation of engine icing, the lack of significant standing water on the runway, and the absence of heavy precipitation. However, it could not be completely discounted and, if flame-out had occurred, the non-incorporation of the FAA mandated auto-relight system would have reduced the possibility of an immediate relight. Approximately six months before the accident, the left engine had failed during a landing roll-out whilst the aircraft was being operated in Spain. This failure was never satisfactorily explained although, at one stage, the fuel cut-off valve came under suspicion. The valves were interchanged, according to the records, so that the unit that had been fitted to the left engine was installed on the right engine, at the time of the accident. Whilst a stray electrical signal causing the valve to close would certainly result in the engine flaming out, rumours that such events had occurred were not substantiated by the engine manufacturer. In summary, the left engine experienced a bird strike, but with no apparent power loss, and the extensive technical examination could not identify any reason for a loss of power on the right engine. Although an engine failure during takeoff after V1 is a serious emergency, the aircraft was at a relatively light weight and, even with an such a failure, the crew should have been able to fly OYBPH safely away. However, if other factors had been involved, the margins for safe flight would have become more critical. These other factors could have included incorrect operation of the NTS system and/or a failure of the feathering system on the right engine, a concurrent power loss from the left engine, or the crew not handling the emergency effectively. There is no doubt that the left engine had been producing power at impact, but a definite conclusion could not be made as to the blade pitch angles of the right propeller. From the evidence of the commander and the propeller examination by the manufacturer, it is probable that the right propeller was close to the feather position at ground impact. The functionality of the NTS and feathering system could not be determined but, as noted earlier, the pre-flight NTS check actually only ensured that oil pressure was available for this system, and did not check the operation of the whole system. With the evidence that only the left engine had ingested birds, there was a possibility that the left engine was not producing maximum power, although the crew considered it was operating normally. The commander could remember that he compared the engine EGT indications, once he had pushed both power levers forward, and recalled that the left EGT was indicating greater than 650°C with the 'Bypass' light on. He then retarded the left power lever until the 'Bypass' light went out, following which the EGT indicated about 630°C. This retardation of the power lever was not required, as the function of the 'Bypass' system is to reduce the fuel flow in order to keep the engine parameters within limits. This reported retardation could, however, have resulted in a lower engine power than was possible within the available limits, possibly with an associated reduction in EGT. While it remains a possibility that the left engine may have experienced a transient power reduction as a result of the bird ingestion, it is likely that the commander's action in retarding the left power lever resulted in a more significant reduction of power. To maintain straight flight, following an engine failure, it is vital to apply sufficient corrective rudder input to maintain the wings essentially level and minimise the drag due to sideslip. In the case of OYBPH, there was a constant turn to the right before ground impact. The commander's recollection was that left rudder had been applied by the co-pilot, but not to full deflection. The amount of rudder deflection required depends mainly on the airspeed and the difference in engine power but, with the wings not level, more deflection was obviously required, and was available. Greater use of rudder would have reduced the overall drag of the aircraft, with consequent improvement in the aircraft's performance. Furthermore, following an engine failure, the second segment climb requirement is to climb from 35 feet to 400 feet at V2 with the landing gear selected to up. The commander did not raise the gear because he did not observe a positive rate of climb. However, evidence from the FDR was that a maximum airspeed of 128 kt was achieved and, as this was some 19 kt higher than the V2 speed, it indicated that the aircraft had a capability to climb which was not being used. These last three factors may have combined to reduce the climb capability of the aircraft to zero and, in that situation, the decision to not raise the gear was correct. However, all these factors were influenced by inappropriate crew actions. Although both pilots had flown together before, the lack of adherence to JAR-OPS conversion requirements may have been partly responsible for their actions during the emergency.
Final Report: