Crash of a Piper PA-60 Aerostar (Ted Smith 600) near Port Keats: 1 killed

Date & Time: Sep 2, 2000 at 2125 LT
Operator:
Registration:
VH-IXG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Port Keats – Darwin
MSN:
60-0567-7961185
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
15000
Captain / Total hours on type:
122.00
Circumstances:
The pilot had submitted a flight plan nominating a charter category, single pilot, Instrument Flight Rules flight, from Darwin to Port Keats and return. The Piper Aerostar 600A aircraft, with 6 Passengers on board, departed Darwin at 2014 Central Standard Time and arrived at Port Keats at 2106 hours after an uneventful flight. The passengers disembarked at Port Keats and the pilot prepared to return to Darwin alone. At 2119 hours the pilot reported taxying for runway 34 to Brisbane Flight Service. That was the last radio contact with the aircraft. Witnesses noted nothing unusual as the aircraft taxied and then took off from runway 34. As a departure report was not received, a distress phase was declared and subsequently a search was instigated. The following morning a number of major structural components of the aircraft, including the outer left wing, were located at a position 24 km north-east of Port Keats aerodrome and close to the aircraft's flight planned track. The main portion of wreckage was found four days later, destroyed by ground impact. The impact crater was located a considerable distance from the previously located structural components and indicated that an inflight breakup had occurred. The accident was not survivable.
Probable cause:
Shortly after departure from Port Keats aerodrome, the pilot lost control of the aircraft for reasons unknown. Aerodynamic loading of the left wing in excess of the ultimate load limit occurred, resulting in an inflight breakup of the airframe. The investigation was unable to determine the circumstances that led to the loss of control and subsequent inflight break-up of the aircraft.
Final Report:

Crash of a Piper PA-31-350 Panther II in Zurich: 1 killed

Date & Time: May 26, 2000 at 2023 LT
Operator:
Registration:
HB-LTC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Geneva
MSN:
31-7952003
YOM:
1979
Flight number:
HBLTC
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1119
Captain / Total hours on type:
9.00
Aircraft flight hours:
8387
Circumstances:
On 25 and 26 May 2000 aircraft HB-LTC was used for a commercial flight from Zurich to Béziers (F) and back. To this end, the pilot made a positioning flight from Geneva to Zurich on 24 May 2000. The reconstruction of the following events is based on recorded radio conversations and witness statements. On 25 May 2000 at approx. 07:20 hrs, the pilot placed a telephone order with the refuelling service of Jet Aviation Zurich AG. According to statements from aircraft refuelling attendant A concerned, the pilot asked for the aircraft to be fully refuelled with aviation gasoline (AVGAS) for a flight to France. When aircraft refuelling attendant A arrived at the aircraft, the pilot was present. The refuelling attendant saw the winglets on the HB-LTC and asked the pilot whether the machine had been modified and therefore needed jet kerosene. Before the pilot could even answer, the refuelling attendant realised, from the square engine housings, that the machine was equipped with reciprocating engines. The pilot confirmed that HB-LTC had been modified but pointed out that this modification involved only the airframe and that the aircraft had not been converted to turboprop operation. Refuelling attendant A then filled the HB-LTC’s four fuel tanks with 372 l of AVGAS 100LL (low lead). The aircraft was therefore fully refuelled and at that time had 726 l of fuel. Refuelling attendant A later reported that he had not noticed markings which described the types of fuel permitted for this aircraft, either on the wing or on the tank seals. During the refuelling operation, which ended at approx. 07:30 hrs, the pilot was in the cockpit. Nobody observed him draining the tanks after refuelling. The seven passengers for the flight to Béziers (F) arrived on 25 May 2000 at about eight o’clock in the morning at the General Aviation Centre (GAC) at Zurich airport. At 08:18:42 hrs the pilot received start-up clearance from Zurich Apron (ZRH APR) and at 08:26:25 hrs indicated that he was ready to taxi. Taxi clearance was granted without delay and the aircraft taxied to the holding point of runway 28. Several passengers later stated that the pilot carried out a run up of the engines while the following time of waiting. At 08:32:01 hrs HB-LTC indicated to aerodrome control (Zurich Tower – ZRH TWR) that it was ready to take off. The aircraft was queued in the traffic and was cleared for take-off at 08:45:27 hrs. The aircraft landed in Béziers (F) some two hours later. On 26 May 2000 between 15:35 and 15:45 hrs HB-LTC was refuelled in Béziers with 107 l of AVGAS 100LL. The aircraft then flew with the same passengers from Béziers (F) back to Zurich, where it landed at 19:10 hrs. Before the flight back to Geneva, the pilot obviously decided to refuel. According to the statements of aircraft refuelling attendant B at approx. 19:45 hrs the pilot ordered “Kraftstoff JET-A1” by telephone. Unlike the telephone conversations of air traffic control at Zurich airport, incoming and outgoing telephone calls made to and from the refuelling service of Jet Aviation Zurich AG were not recorded. The precise wording of the pilot’s fuel order cannot therefore be established with certainty. Aircraft refuelling attendant B then forwarded the order by radio to his colleague, aircraft refuelling attendant C. A third aircraft refuelling attendant D heard on his radio how aircraft refuelling attendant B gave the instruction to aircraft refuelling attendant C to refuel aircraft HB-LTC with JET A-1 fuel. Then aircraft refuelling attendant C drove tanker FL 7 to HB-LTC, which was parked in GAC Sector 1. According to his statements, he positioned the tanker with its right-hand side in front of the aircraft so that he could reach the filler caps on both wings using the hose affixed to that side of the tanker. Then aircraft refuelling attendant C, still next to the tanker, began to complete the delivery note, while the pilot came up to him and indicated the desired quantity of fuel in English. The pilot gave him a credit card and aircraft refuelling attendant C then explained to him that after refuelling he would have to complete the transaction in the office. The pilot remarked that he had a slot. Aircraft refuelling attendant C later stated that this gave him to understand that the pilot did not have much time. The aircraft refuelling attendant replied to the pilot that he would only need an additional two or three minutes. Because it had started to rain shortly before refuelling, the pilot evidently withdrew into the aircraft after his conversation with aircraft refuelling attendant C. According to his partner, the pilot conducted a brief conversation with her from his mobile telephone during this phase. As the investigation showed, this telephone call took place between 19:50:06 and 19:51:28 hrs. In the meantime, aircraft refuelling attendant C had connected HB-LTC to the tanker and then pumped 50 l of JET A-1 fuel into each of the two inboard main cells. The aircraft refuelling attendant later stated that he had not noticed markings or labels which described the permitted types of fuel for this aircraft, either on the tank seals or in the vicinity of the tank openings. He then drove the tanker to the office, debited the credit card and returned it with the receipt and the delivery note to the aircraft. He presented the debit slip and the delivery note to the pilot for signature. In the process the aircraft refuelling attendant asked the pilot what aircraft type HB-LTC was. The pilot answered that his aircraft was a modified PA31. The aircraft refuelling attendant then entered “PA31” on the delivery note and then gave the pilot the carbon copy. At 20:08:44 hrs the pilot made radio contact with Zurich Clearance Delivery (ZRH CLD) air traffic control and received departure clearance with the instruction to change to the ZRH APR frequency for start-up clearance. The apron gave HB-LTC start-up clearance at 20:10:00 hrs. Three minutes and 50 seconds later the pilot requested taxi clearance and was then instructed to taxi to the holding point of runway 28. After the transfer to ZRH TWR at 20:15:02 hrs the pilot stated he was ready for take off at 20:17:30 hrs. A short time after this he was able to line up runway 28 and at 20:20:58 hrs ZRH TWR gave him take-off clearance. According to witness statements, HB-LTC took off normally and went into a climb. In the region of runway intersection 28/16 and at an altitude of approx. 50 m AGL the aircraft stopped climbing, maintained level flight briefly and began to descend slightly. At the same time, HB-LTC began to make a gentle right turn and overflew the woods to the north of runway 28. Because of this unusual flight pattern, the duty aerodrome controller (ADC) at 20:22:08 hrs asked the pilot whether everything was normal: “Tango Charlie, normal operations?” The pilot replied in the negative: “(Ne)gative, Hotel Tango Charlie!” In this phase, the aircraft began to make a left turn with a high bank angle and witnesses observed that the landing gear was lowered. At 20:22:21 hrs the pilot radioed that he was in an emergency situation: “Mayday, Mayday, Mayday, Hotel Tango Charlie”. During the first 90° of the turn, HB-LTC descended only slightly. After crossing the extended centerline of runway 28 the aircraft increasingly lost height in the tight left turn. When the aircraft had almost completed the full turn, its bank attitude began to reduce. At a height of approx. 10 m AGL HB-LTC collided with the trees in a copse. The aircraft passed through the copse and came to rest upside down in the “Glatt” river. The pilot was fatally injured on impact. Coordinates of the final position of the wreck: 682 700/256 700, elevation 420 m AMSL corresponding to 1378 ft AMSL.
Probable cause:
The investigation established the following causal factors for the accident:
• A misunderstanding occurred when the fuel was ordered.
• The refuelling attendant concerned did not notice the fuel grade rating placards attached to the aircraft.
• The refuelling attendant concerned did not realise that the aircraft was equipped with reciprocating engines.
• The pilot did not notice the fuel grade rating placards on the tanker vehicle.
• The pilot did not realise the incorrect refuelling on the receipt for the fuel provision.
The following factors allowed or favoured the occurrence of the accident:
• The delivery nozzle on the filler gun was of an outside diameter which allowed the aircraft involved in the accident to be refuelled.
• The level of training and knowledge of the refuelling personnel concerned was inadequate.
• The Federal Office for Civil Aviation never inspected the refuelling operation before the accident.
• Until the time of the accident, the Federal Office for Civil Aviation had issued no regulations on the training of refuelling personnel, the size of delivery nozzles and tank openings on aircraft or on the identification of filler guns and tank openings.
The following points may have exacerbated the outcome of the accident:
• The pilot decided on an about turn which brought him onto a collision course with obstacles.
• The retention mechanism of the safety belt was not working.
Final Report:

Crash of a PZL-Mielec AN-28 off Inebolu: 6 killed

Date & Time: Dec 29, 1999 at 1700 LT
Type of aircraft:
Operator:
Registration:
3C-JJI
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kiev - Tehran
MSN:
1AJ004-14
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
On a ferry flight from Kiev to Tehran, while in cruising altitude over the Black Sea, the crew reported an unexpected situation and requested a clearance to divert to Ankara Airport. Shortly later, the twin engine aircraft went out of control and crashed in the sea about 50 km off Inebolu. Few debris were found floating on water but the wreckage was not found. All six occupants were killed.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined.

Crash of a Cessna 208 Caravan I in Hillsborough

Date & Time: Aug 13, 1999 at 1311 LT
Type of aircraft:
Registration:
N193GE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Manchester - Denver
MSN:
208-0193
YOM:
1991
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10530
Captain / Total hours on type:
3000.00
Aircraft flight hours:
6132
Circumstances:
With an auxiliary fuel tank system installed, the pilot filled the tanks and departed. A few minutes later, he noticed fuel on the floor of the cabin, and tried to reach an airport. However, the fuel fumes were so strong he elected to land in an open field. After touchdown, the airplane passed through a ditch the pilot had not observed from the air. The nose landing gear collapsed and the airplane nosed over. An airborne witness reported the pilot exited the airplane after about 5 minutes, and about 5 minutes later, the airplane caught fire and burned. The post crash fire consumed the cabin. In an interview, the pilot reported that he had not initiated use of the auxiliary fuel tank system when the accident occurred. He also reported he could not see where the fuel was coming from. The investigation revealed the tank installation did not match the FAA Form 337, the instructions for use of the ferry tank system were inadequate, and the pilot had reported that the auxiliary fuel pumps were secured to a board which was not secured to the airplane.
Probable cause:
An inadequate auxiliary fuel tank installation which resulted in a leak of undetermined origin.
Final Report:

Crash of a Piper PA-31-310 Navajo C near Pescara: 2 killed

Date & Time: Jul 15, 1999
Type of aircraft:
Operator:
Registration:
G-NAVO
Flight Phase:
Flight Type:
Survivors:
No
MSN:
31-8212031
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following an uneventful cargo flight to Pescara, the crew was returning to UK. Few minutes after takeoff from Pescara Airport, the crew encountered poor weather conditions. Control was lost and the aircraft crashed, killing both occupants.

Crash of a Cessna 414 Chancellor in Orland

Date & Time: May 21, 1999 at 1725 LT
Type of aircraft:
Registration:
N8153Q
Flight Type:
Survivors:
Yes
Schedule:
San Jose – Redding
MSN:
414-0053
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
480.00
Aircraft flight hours:
4471
Circumstances:
The pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidly decaying altitude, and power. During the landing roll, the airplane collided with a ditch. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synthetic polymer that is used as an agricultural soil amendment that aids in reducing soil erosion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be improperly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminates with no caps or covers for protection.
Probable cause:
A loss of engine power in both engines due to fuel contamination, which resulted from the fueling facilities improper quality control procedures.
Final Report:

Crash of a Beechcraft A100 King Air in Irati

Date & Time: Apr 14, 1999 at 1200 LT
Type of aircraft:
Operator:
Registration:
PT-LZA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Foz do Iguaçu – Curitiba
MSN:
B-200
YOM:
1974
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1320
Copilot / Total hours on type:
60
Circumstances:
The crew departed Foz do Iguaçu Airport at 2215LT on a ferry flight to Curitiba. About 55 minutes into the flight, while in cruising altitude by night, the right engine failed, followed few seconds later by the left engine. The crew reduced his altitude and attempted an emergency landing when the aircraft crashed in a grassy area near Irati. While the copilot escaped uninjured, the captain was injured. The aircraft was destroyed.
Probable cause:
Failure of both engines in flight due to fuel exhaustion. The following findings were identified:
- The crew failed to prepare the flight according to published procedures,
- The crew failed to check there was sufficient fuel in tanks prior to departure,
- The crew failed to follow the pre takeoff checklist,
- The captain showed excessive self confidence
- The captain exercised pressure on the copilot,
- The crew suffered fatigue due to an excessive period of work. At the time of the accident, the crew was overduty by three hours,
- The crew consumed alcohol beverages the night before the flight.
Final Report:

Crash of a Cessna T303 Crusader near Nottingham

Date & Time: Jul 16, 1998 at 1833 LT
Type of aircraft:
Registration:
G-BSPF
Flight Type:
Survivors:
Yes
Schedule:
Sheffield – Nottingham
MSN:
303-00100
YOM:
1982
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
290
Captain / Total hours on type:
68.00
Circumstances:
The aircraft was en route from Sheffield City Airport to Nottingham where it was based. The pilot joined the traffic zone at Burton Joyce, an unofficial but well used Visual Reporting Point, at a height of about 1,000 feet. The weather was fine with good visibility and the pilot took the opportunity to view the house of the aircraft's co-owner located in the vicinity of Burton Joyce. While orbiting the house, the pilot felt a moderate 'bumping' sensation which he attributed to thermal activity rather than pre-stall buffet. The left wing suddenly dropped and the aircraft rolled through the vertical. The pilot applied corrective rudder and moved the control column forward which rolled the aircraft erect but he was unable to arrest the rate of descent because the engines did not appear to be developing full power. He therefore elected to carry out a forced landing with the landing gear retracted. On approaching the field, the aircraft struck a telegraph pole, yawed to the left and landed with a very high rate of descent before coming to a halt after a short ground slide. The pilot was unable to evacuate the aircraft because of his injuries but was rescued by local people who were quickly on the scene. There was no fire. The pilot stated that at the time the aircraft departed from normal flight, he was flying at about 100 kt with 60° of bank. The basic stalling speed of the aircraft in the configuration at the time was about 70 kt. Application of the correction for load factor in the turn would have given a stalling speed of 100 kt. The majority of eye witnesses stated that the aircraft was very low at the point at which it departed from normal flight, probably in the region of 300 feet above ground level.
Final Report:

Crash of a Rockwell Grand Commander 680 in the Atlantic Ocean: 1 killed

Date & Time: Apr 9, 1998
Operator:
Registration:
4X-CCS
Flight Phase:
Flight Type:
Survivors:
No
MSN:
680-1731-138
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, departed Southend on a ferry flight to Canada with an intermediate stop in Greenland. En route, he reported to ATC severe icing conditions. Shortly later, the aircraft entered an uncontrolled descent and crashed in the Atlantic Ocean about 167 km southeast of the Greenland coast. The pilot was killed.

Crash of a Piper PA-31-350 Navajo Chieftain on Mt Kilimandjaro: 1 killed

Date & Time: Nov 1, 1997 at 1020 LT
Operator:
Registration:
5H-AZM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nairobi - Zanzibar
MSN:
31-8052207
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Circumstances:
On 1 November 1997 at 09:46 hours 5H-AZM took off from Nairobi Wilson airport, for a visual flight rules flight to Zanzibar International Airport, Tanzania. It was carrying one pilot and some cargo. There were no passengers. The flight plan indicated that the aircraft had 0330 hours of fuel on departure. The pilot planned' to fly a direct route to Zanzibar with Dar-es-salaam International airport as his alternate aerodrome. After take off from Nairobi Wilson, the flight transited the southern axis lane of the Nairobi control Zone to the zone boundary. The pilot checked the Nairobi zone boundary with Nairobi Wilson Tower and was instructed by air traffic control to contact the Nairobi Control Centre. No contact was reported established by Nairobi Control with 5H-AZM. 5H-AZM contacted the Kilimanjaro Control Tower at 10:20 hours and passed his own ward estimates as Flight Information Region 10:25 hours and arrival at Zanzibar at 11:40 hours. 5H-AZM was advised that there was no reported traffic for the flight in the Kilimanjaro Terminal Control area at 'the VFR flight level 115, and at the same time instructed the aircraft to contact Dar-es-salaam Control on 119.6 MHz when in range. No further transmission was received from the aircraft. It also failed to arrive in Zanzibar. Unfruitful formal searches (involving communications, aerial and ground searches) were mounted on 3 November 1997 along the probable route area in Kenya and Tanzania. The formal search was terminated on 4 December 1997 and there after the missing aircraft incident was considered to be an 'accident. Wreckage was eventually located in the Kibo Crater near the summit of Mount Kilimanjaro in Tanzania on 28 August 2003, almost six years later. The wreckage of the Piper PA 31-350 was found at 15,400 feet on the Kibo wing. It was also 30 nautical miles west of its projected track. The aircraft had earlier been cleared to climb from 9,500 feet to 11,500 feet under visual flight rules.
Probable cause:
Controlled flight into terrain for unknown reasons.