Ferry

The aircraft collided with mountainous terrain in a level descent during a visual approach to the destination airport. According to recorded radar data, 10 minutes after descending from 15,000 feet, the flight impacted about 200 feet below the top of the partially obscured ridgeline (elevation of 2550 feet), and 8 miles from the destination. The data indicates the flight path was similar to the global positioning satellite (GPS) approach to the airport. Six minutes before the accident, and the pilot's last transmission to air traffic control, he was informed and acknowledged that radar service was terminated. The flight was 12.4 miles from the accident site when radar contact was lost. Reduced visibility due to fog hampered search & rescue efforts, and the aircraft wreckage was located the next day. The aircraft was equipped with a GPS navigation system; however the installation was incomplete, restricting its use to visual flight rules (VFR) only. The investigation did not determine if the GPS was being used at the time. A non-enhanced Ground Proximity Warning System was also installed. The maximum elevation figure listed on the sectional aeronautical chart covering the area of the accident site and destination airport was 3000 feet mean sea level. The chart also shows an advisory for the area to use caution due to rapidly rising.

The pilot completed a flight without incident, and seemed in good spirits before departing, by himself, on the return flight. The second flight also progressed without a incident until cleared from 8,000 feet msl to 5,000 feet msl, which the pilot acknowledged. Visual meteorological conditions prevailed at the time, and radar data depicted the airplane initiate and maintain a 500-foot per-minute descent until radar contact was lost at approximately 400 feet agl. The pilot made no mention of difficulties while en route or during the descent. The airplane impacted trees at the top of a ridge in an approximate level attitude, and came to rest approximately 1,450 feet beyond, at the bottom of a ravine. Examination of the wreckage revealed no preimpact failures or malfunctions. The pilot had been diagnosed with Crohn's disease (a chronic recurrent gastrointestinal disease, with no clear surgical cure) for approximately 35 years, which required him to undergo several surgeries more than 20 years before the accident. The pilot received a letter from the FAA on June 11, 1998, stating he was eligible for a first-class medical certificate. In the letter there was no requirement for a follow up gastroenterological review, but the pilot was reminded he was prohibited from operating an aircraft if new symptoms or adverse changes occurred, or anytime medication was required. His condition seemed to be stable until approximately 5 months prior to the accident. During this time frame, he experienced weight loss and blood loss, was prescribed several different medications to include intravenous meperidine, received 3 units of blood, and had a peripherally inserted central catheter placed. On the pilot's airmen medical application dated the month prior to the accident, the pilot reported he did not currently use any medications, and did not note any changes to his health. A toxicological test conducted after the accident identified meperidine in the pilot's tissue.

The aircraft was leaving Moscow on a ferry flight to St Petersburg following a charter flight from Sochi. On board were 16 crew members, among them 10 employees of the company. Two seconds after takeoff from runway 07L, while climbing to a height of about 200 metres, the stabilizers trimmed to the full up position of 12°. The aircraft nosed up and reached a super critical angle of attack. The crew attempted to regain control by pushing the control column forward but the aircraft stalled and crashed in a huge explosion about 700 metres past the runway end. Two stewardesses were injured while 14 other occupants were killed.

On the day of the accident, the aircraft departed Abuja with the call Sign SXC401 en route Port Harcourt conveying 2 passengers on revenue basis. Before the commencement of the flight, the Chief Engineer was reported to have replaced the "Carbon brush" of the starboard starter generator. The source of this pair of carbon brushes is questionable. This flight was uneventful as the passengers disembarked and the aircraft picked up fuel for Port Harcourt. The aircraft departed Port Harcourt at 1750 hrs UTC with five souls on board (all crewmembers), estimating Calabar at 1827 hrs UTC. At 1800 hrs UTC, the aircraft was in contact with Calabar Tower at 5,000 feet, reporting 5 Souls-On-Board and an endurance of 3 hrs 30 minutes. The crew also requested for the hourly weather report and the control tower passed the 1700 hours weather report as "surface wind 140°/ 09 knots, visibility 10km, slight thunderstorm, cloud base scattered 300 metres, few CB N-SE 690 m broken at 9,000 m, QNH 1008 and temperature 27°C". The aircraft was also instructed to maintain the 5,000 feet level and to expect no delay for the VOR approach to runway 03. At 1809 hrs UTC, the aircraft was at 35 nautical miles to the station when the pilot requested for descent clearance and the controller gave him a clearance to 2,500 feet and to position for a straight-in approach to runway 03 and the crew acknowledged. At 1824 hrs UTC, the pilot reported having electrical problem and therefore declared emergency. Thereafter, the pilot requested for increase in the intensity of the approach lights, the controller informed him that the approach lights were, already, at their maximum intensity. The controller procedurally then requested for the aircraft's altitude but the response of the pilot was "we are coming to Calabar" and at 1830 hrs the aircraft reported 16 nautical miles to Calabar. The control tower at 1833 hrs UTC, wanted to establish the position of the aircraft by requesting repeatedly "Your position? Your position?" to which the response was "standby, standby". The verbal query continued until 1842 hrs and when there was no response from the aircraft, the controller alerted the airport fire services to be on the standby for further instructions. When the controller could no longer establish contact with the aircraft, he then contacted the relevant agencies for search and rescue operations. Meanwhile, the aircraft on descent impacted trees and crashed in a marshy area located 22 km from the airport. The aircraft was destroyed and all five occupants were killed.

Following an uneventful flight from Mogadishu, the crew started the descent to Djibouti City-Ambouli Airport. While the runway 09 was in use, the crew was cleared for an approach to runway 27. While completing a last turn to the left to join the glide, the aircraft went out of control and crashed in the sea. All four occupants were killed.

The aircraft departed Budapest-Ferihegy Airport at 0829LT on a VFR flight to Tunis. According to the flight plan the aircraft would fly over Split, Pescara, crossing the Apennines towards Ostia and then onwards to Tunis. Weather conditions over the central part of Italy were poor with a cold front associated with thunderstorm activity, low clouds and icing conditions. After passing over the Adriatic sea, the aircraft overflew Pescara at 1320LT where the pilot informed ATC that the aircraft was inbound Aneda (a reporting point 19 NM East of Monte Rotondo) at a cruising altitude of 5.500 feet. While in vicinity of Pescara, ATC requested and obtained confirmation from the crew that he was able to continue under VFR mode. Shortly later, at a speed of 115 knots, the single engine aircraft struck the slope of Mt Rotondo (1.880 metres high) located near Rocca di Mezzo. The aircraft disintegrated on impact and all three occupants were killed.

At 19:43:49 UTC the crew of EAB 220 called clearance delivery (CLD) for the first time and asked if their flight plan to Bern-Belp was available. The answer was in the affirmative and the CLD air traffic controller informed the crew that they would need authorisation for the landing in Bern-Belp. Once it had been clarified that this authorisation had been obtained, EAB 220 called back a little later. CLD informed the pilots that their departure was planned from runway 34. However, they would have to expect a delay at that time, as arrivals and departures were being handled in batches. EAB 220 was scheduled in the next batch for take-off. CLD intimated to the crew an approximate departure time of 20:30 UTC. When the crew called back at 20:13:49 UTC to ask for any news, CLD informed them that departure would now take place in about 45 minutes. Since visual conditions were deteriorating due to the thickening fog, air traffic control had to increase the separation between arriving aircraft. As a result, flight EAB 220’s estimated departure time was delayed to about 21:00 UTC. At 20:24:38 UTC CLD transmitted to the crew a departure clearance. Flight EAB 220 was assigned the standard instrument departure (SID) “WILLISAU 3N” and transponder code 1403. In addition, a departure time of 21:07 UTC was estimated. The CEO of Eagle Air Ltd. had applied in Bern-Belp for a special authorisation for a late landing after 21:00 UTC and obtained a slot until 21:30 UTC at the latest. Since the departure of HB-VLV in Zurich was being further and further delayed, the crew found themselves under increasing time pressure. The crew were in contact with the CEO several times; at the time, the latter was performing the function of the dispatcher. In order to ensure the arrival of HB-VLV in Bern-Belp by 21:30 UTC at the latest, he also telephoned the duty manager in Zurich control tower and urged him several times for an earlier departure time. After a frequency change to apron control, the apron controller cleared EAB 220 to start its engines at 20:43:50 UTC. Approximately at the same time, an airport manager observed that HB-VLV’s right-hand engine was running, although only one pilot was present in the cockpit. He was sitting in the right-hand seat. The other crew member, probably the commander, was using a scraper to remove ice deposits from the left wing. The eye witness later observed how this crew member occupied the left-hand position in the cockpit, shortly before taxiing. Since the pilots were eager to leave their stand in the General Aviation Centre (GAC) Sector 1 as quickly as possible, they were cleared to taxi as far as the holding point for runway 28 just 2 minutes later. There they had to wait for a taxiing Saab 2000 to pass in the opposite direction. EAB 220 was then instructed by the apron controller to continue taxiing to the holding point for runway 34 via taxiways ALPHA, INNER and ECHO. One minute after taxi clearance had been given, the crew of EAB 220 again asked for the wording of this clearance: “Swiss Eagle 220, sorry for that, can you say the clearance again?” It must remain open whether HB-VLV had missed the intersection in the direction of the INNER taxiway. It is clear, however, that the apron controller had to intervene shortly afterwards with a correction: “220, continue on taxiway INNER, INNER, and then ECHO to Holding Point 34, Echo 9”. At 20:56:50 UTC flight EAB 220 made contact with Aerodrome Control (ADC) and stated that the aircraft was on Echo 9 just before the start of runway 34. The air traffic controller (ATCO) requested the crew to wait short of runway 34, since approaches were still taking place in the opposite direction on runway 16. At 21:04:51 UTC ADC cleared the aircraft to line up on runway 34. The crew taxied onto runway 34 and – after they had received take-off clearance at 21:05:54 UTC – initiated a rolling take-off by setting take-off power. At this time, meteorological visibility was 100 m with partial fog. Since the left-hand engine was run up within six seconds to 102 percent of take-off power and the right-hand engine to 58 percent, for a few seconds during the acceleration phase the aircraft veered on the runway to such an extent that it’s heading changed 10 degrees to the right. The crew were only able to bring the aircraft back into alignment with the runway by making a major nose-wheel control correction and by distinctly reducing the thrust of the left-hand engine. Afterwards the two engines were brought synchronously to take-off power and the take-off continued. Flight EAB 220 lifted off from runway 34 at 21:06:40 UTC. Shortly after take-off, the commander of EAB 220 acknowledged the request to change frequency to departure control. At about the same time various members of the airport fire-fighting services, who were inside and in front of the fire-fighting unit satellite “North” between runways 34 and 32, heard noises and saw visual indications of a low-flying aircraft. Immediately afterwards the noise of a crash and the flash of a fire were noted. At 21:07 UTC the aircraft impacted onto the frozen ground 400 m to the south-east of the end of runway 34 and skidded in a northerly direction, leaving a trail of debris. The main body of the wreck finally came to rest 500 m beyond the site of initial impact on runway 14/32. The rescue services reached the burning wreck after a few minutes. DFDR data revealed that the autopilot was disengaged during the whole flight.

Following an uneventful ferry flight from Braunschweig, the crew was cleared to land on runway 27 at Bremen-Neuenland Airport. After touchdown, the crew started the braking procedure and activated the reverse thrust systems on both engines. At a speed of 60 knots, the aircraft deviated to the right so the captain applied left rudder. The aircraft turn 15° to the left so the captain applied right rudder when the aircraft turned 135° to the right. This turn was so abrupt that it caused the left main gear to collapse. The aircraft rolled for about 1,150 metres before coming to rest. All three crew members evacuated uninjured while the aircraft was damaged beyond repair.

At 1623:41, the pilot requested taxi clearance. The Green Bay (GRB) tower (ATCT) told the pilot to taxi to runway 18. At 1626:47 the pilot said that he was ready for takeoff. The ATCT local controller (LC) told the pilot, "proceed on course, cleared for takeoff". At 1627:33, radar showed the airplane began to accelerate down runway 18. At 1628:17 the LC told the pilot to contact departure control. The pilot responded, "ah papa charlie we have a little problem here we're going to have to come back." The LC asked the pilot, "what approach would you like?" The pilot responded, "like to keep the vis." At 1628:35, the LC asked the pilot, "like the contact approach that what you're saying?" There was no response from the pilot. At 1628:50, GRB radar showed the airplane on a heading of 091 degrees, at an altitude of 855 feet msl (160 feet agl), and at an airspeed of 206 knots. The airplane was 1.28 miles southeast of the airport radar. Radar contact with the airplane was lost at 1628:55. A witness to the accident said, "It was snowing moderately at that time. The road was wet but not slippery. Crossing the intersection of Morning Glory Rd. & Main St., I noted a white private jet flying from the south. It was flying at approximately a 75-80 degree angle perpendicular to the ground with its left wing down & teetering slightly." The witness said, "It then crossed Main Street with the lower wing tip approximately 20 to 30 feet above the power wires. The plane became more perpendicular to the ground at a 90 degree angle with the left wing down & (and) lost altitude crashing into the Morning Glory Dairy warehouse building." An examination of the airplane revealed no anomalies. At 1638, GRB weather was reported as ceilings of 200 feet broken, 800 feet overcast, visibility 1/2 statute mile with snow and fog, temperature 32 degrees F, dew point 32 degrees F, winds 120 degrees at 3 knots, and an altimeter setting of 29.99 inches Hg. Witnesses at the FBO said the pilot arrived to pick up the airplane after 1600. The pilot was briefed by the mechanic as he did his walk around inspection of the airplane. The pilot then
got into the airplane. The airplane was towed out and the tow bar removed. About two minutes later, the engines started. Less than five minutes after the engines started, the airplane taxied. The NTSB Audio Laboratory reviewed radio communications between ATCT and the pilot to determine from the speech evidence the pilot's level of psychological stress and workload. The examination indicated the pilot's speech characteristics were consistent with an increased stress/workload that might accompany a developing emergency. Referring to the pilot's final transmissions, "His unusually long reaction time suggests that he was distracted by competing cockpit priorities and/or was having a difficult time determining his answer, while his fast speech and microphone keying provide further evidence of an urgency to return to other cockpit activities." The report states that the pilot's statements remained rational and showed good word choice and grammar. "These factors, along with the relatively small change in fundamental frequency, suggest that the pilot did not reach an extreme level of stress."

During an inspection of the right engine a technician found chips in the oil filter. The damage should have been repaired within the next 20 flight hours. Since the maintenance organization in Switzerland, who usually carry out necessary repairs, did not have the spare parts available on time, the task was assigned to an organization in Nuernberg. On 07.02.2001, the airplane was ferried to Nuernberg and repaired in the presence of the chief technician of the operator. The repairs and the replacement of the parts exclusively on the right engine were certified properly. The return flight to Rome was planned for the 8th of February 2001 at about 1530 o’clock. A charter flight from Rome was to be carried out on the following day. Two pilots and the chief technician of the operator were aboard the aircraft. The flight preparation was carried out by phone from the repair facility. A weather briefing and the NOTAM´s for the flight were obtained properly. The check lists for the take-off were read. During the preparation the unbalanced fuel distribution between the right and left-hand tanks, and the fact that the total amount yet was equal on both sides was discussed. Immediately afterwards the second pilot noticed the failure of his gyro instruments. The airplane was taxied via the taxiways "Juliet" and "Foxtrot" to runway 10. Pilot at the controls was the pilot in command while the second pilot carried out the radio communications with the air traffic control. The pilots received the clearance for a departure via the departure route Noerdlingen (NDG 1 M) to Rome. The take-off was at 1531 o'clock. After 5 nautical miles the airplane turned to the south, following the departure route. At 15:33:49 o'clock the left-hand engine failed without a previous warning. The noise of a down running engine was also heard by several witnesses on the ground. Smoke or a fire was not seen by them. The second pilot reported an emergency with the left-hand engine shortly after the occurrence to the control tower and informed them that they wanted to return for a landing on the runway 10. At that time there were visual meteorological conditions, and the runway was continuously to be seen. Since the departure control Nuernber APP wished to coordinate the flight, the frequency was changed for a short time upon request. After the second pilot had declared the emergency once again they switched back to the tower again and continued the approach to runway 10. Up to the final approach the flight was without particular occurrences. The flaps were first set to 8° and later on to 20°, afterwards the landing gear was extended. At this time the airplane was somewhat north of the extended centerline slightly above the glide path for an instrument approach. Approximately one kilometer in front of the runway, when flying over the main road no. 4 near the small town of Buch, the airplane was observed by different witnesses as it made unusual flight maneuvers. The airplane deviated then from the landing direction to the north, and made some reeling movements. Afterwards it seemed for a short
period that the pilot intended to turn right to reach the runway. Immediately afterwards and near the ground the airplane abruptly stalled to the left approximately maintaining its height, then assuming a bank angle of more than 90°, and crashed nearly upside down at 1540 o’clock into a forest north of the runway. The airport fire service, who were in a standby position due to the announced safety landing of the Learjet reached the accident site approximately 4 minutes later and started to extinguish the fire. All three occupants had lost their lives during the impact. The airplane was destroyed.