Crash of a Fairchild-Hiller FH-227D in Ambato

Date & Time: Oct 28, 1997 at 1617 LT
Type of aircraft:
Operator:
Registration:
HC-BUF
Flight Type:
Survivors:
Yes
Schedule:
Quito - Ambato
MSN:
573
YOM:
1968
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Quito-Mariscal Sucre Airport, the crew started the descent to Ambato Airport in good weather conditions but was stressed by the presence of another aircraft in the approach area. On approach, the aircraft was too high on the glide and its speed was 100 knots, about 12 knots above the reference speed. This caused the aircraft to land too far down the runway 19, about 900 metres past the runway threshold (Ambato's runway 19 is 2,000 metres long). After touchdown, the crew decided to initiate a go-around procedure and increased engine power. The aircraft adopted a high angle of attack, causing the base of the empennage to struck the runway surface. Out of control, the aircraft continued, overran and came to rest in a ravine located 60 metres past the runway end. All seven occupants escaped with minor injuries and the aircraft was damaged beyond repair.
Probable cause:
The following findings were reported:
- Wrong approach configuration as the aircraft was too high on the glide with an excessive speed,
- The aircraft landed too far down the runway, reducing the landing distance available,
- Poor flight planning,
- Poor crew coordination,
- The copilot failed to calculate properly the approach and landing speeds,
- The captain was not aware of the total weight of the aircraft upon landing,
- The operator failed to train the crew according to the specificities related to Ambato Airport,
- The operator failed to prepare documentation required for the operations at Ambato Airport,
- When the crew initiated the go-around procedure, the aircraft' speed was insufficient, and the input on the control column was sudden, causing the base of the empennage to struck the runway surface.

Crash of a De Havilland DHC-2 Beaver off Ketchikan: 1 killed

Date & Time: Sep 29, 1997 at 1747 LT
Type of aircraft:
Operator:
Registration:
N4787C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Ketchikan - Ketchikan
MSN:
1330
YOM:
1959
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2071
Captain / Total hours on type:
1200.00
Aircraft flight hours:
24267
Circumstances:
The float equipped airplane was observed taking off in light winds and calm water, and obtaining a steep climb and nose high attitude. Witnesses described hearing no reduction of engine noise from takeoff power to climb power. The airplane entered a steep left bank about 200 feet above the water, then rolled rapidly to the right and impacted at a steep angle into the water. The airplane had been modified with a Short Take Off and Landing (STOL) kit. Certification flight tests had determined that this modification eliminated aerodynamic warning of impending stalls, and therefore required an audible stall warning. Test results also required the addition of both a ventral fin, and horizontal stabilizer finlets, to meet directional stability certification. These tests determined that the least stable condition was in the takeoff flap configuration, during climb. The Supplemental Type Certificate (STC) for the modification required the ventral fin, and an audible stall warning system be installed. The manufacturer provided a marketing video, produced prior to the STC approval, which stated the stall warning system was not required in the U.S. The company indicated this tape was used for training, and was a basis for pilots routinely disabling the stall warning horn by pulling the circuit breaker. At the time of the accident, the airplane did not have the ventral fin installed, a takeoff flaps setting was selected, and the audible stall warning circuit breaker was in the pulled (disabled) position. The local FAA Flight Standards Office had inspected the accident airplane 14 times in the previous 29 months, and made no mention of the ventral fin not being installed.
Probable cause:
The pilot's excessive climb and turning maneuver at low altitude, the pilot's inadvertent stall, and the intentional operation of the airplane with the required stall warning system disabled. Factors associated with this accident were the pilot's overconfidence in the modified airplane's ability, the uninstalled ventral fin, inadequate compliance with the STC by the company, unclear information by the manufacturer, and inadequate surveillance by the FAA.
Final Report:

Crash of a Learjet 31 in Aberdeen

Date & Time: Sep 2, 1997 at 1020 LT
Type of aircraft:
Operator:
Registration:
N71JC
Flight Type:
Survivors:
Yes
Schedule:
Madison - Aberdeen
MSN:
31-008
YOM:
1989
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19947
Captain / Total hours on type:
1860.00
Aircraft flight hours:
1845
Circumstances:
According to the pilot, the airplane was high and fast on final approach, because of restricted visibility in haze, and he executed a go-around. The pilot and copilot do not recall retracting the landing gear. During the second approach, the pilot stated he did not extended the gear because he was 'sure in his mind that the gear was already down'. The airplane landed with the gear retracted. The airplane slid approximately 3,000 feet. Following the landing, the airplane caught fire under the right wing root, and the fire could not be extinguished with hand held fire extinguishers. Both pilots safely evacuated the airplane.
Probable cause:
The flightcrew's failure to extend the landing gear.
Final Report:

Crash of a Beechcraft 200 Super King Air in Dalton: 1 killed

Date & Time: Aug 14, 1997 at 0611 LT
Operator:
Registration:
N74EJ
Flight Type:
Survivors:
No
Schedule:
Athens - Dalton
MSN:
BB-340
YOM:
1978
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2398
Captain / Total hours on type:
103.00
Aircraft flight hours:
6328
Circumstances:
The pilot was cleared for a localizer approach by Atlanta Center and told to maintain 5,000 feet until crossing the final approach fix (FAF). Normal altitude at the FAF was 2,700 feet. The pilot was unable to land from this approach and performed a missed approach. He was handed off to Chattanooga Approach, then was cleared to cross the FAF at 3,000 feet and perform another localizer approach. About one mile from the FAF, the pilot was told to change to the airport advisory frequency. The pilot acknowledged, then there was no further communication with the aircraft. A short time later, witnesses heard the aircraft crash near the approach end of the runway. Examination of the crash site showed the aircraft had touched down in a grass area about 1,100 feet from the end of the runway, while on the localizer. Propeller slash marks showed both engines were operating at approach power and the aircraft was at approach speed. No evidence of precrash mechanical failure or malfunction of the aircraft structure, flight controls, systems, engines, or propellers was found. The 0621 weather was in part: 300 feet overcast and 1/2 mile visibility with fog. Minimum descent altitude (MDA) for the localizer approach was 1,180 feet msl; airport elevation was 710 feet. The pilot had flown 8 flight hours, was on duty for 13.6 hours the day before the accident, was off duty for about 6 hrs, and had about 4 hours of sleep before the accident flight.
Probable cause:
The pilot's improper IFR procedure, by failing to maintain the minimum descent altitude (MDA) during the ILS localizer approach, until the runway environment was in sight, which resulted in a collision with terrain short of the runway. Factors relating to the accident were: darkness, low ceiling, fog, pilot fatigue, and improper scheduling by the aircraft operator.
Final Report:

Crash of a Learjet 35A in Avon Park

Date & Time: Jul 15, 1997 at 1953 LT
Type of aircraft:
Registration:
N19LH
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Avon Park
MSN:
35-279
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20076
Captain / Total hours on type:
1500.00
Aircraft flight hours:
13726
Circumstances:
Witnesses near the airport saw the flight approach on a left base to runway 4, touchdown on the runway, and takeoff again. One witness, a pilot, said the airplane turned onto final to the 'south' (right) of the runway centerline.' The airplane made a 'sharp' turn to the left to realign with the runway center, slightly overshot the runway to the left, turned to the right 'sharply,' and touched down on the runway. The witness further stated, '...by the time the pilot was on the runway he had wasted approximately 1,200 to 1,500 feet of runway 4, they hit reverse thrusters [sic] and were on full bore till they crossed runway 27 and 9.' The witness saw heat come out of both engine thrust reversers, the nose gear touched down and then came up again. He then saw the airplane come off the ground about 30 to 40 feet, wobble left and right at a 'slow airspeed,' crossover a highway at a low altitude, right wing low, strike some wires, go into a field, and catch fire. The pilot said, when he touched down on the runway, the airplane seemed to 'lurch' to the side. He said at this point his airspeed was 126 knots. He elected to abort the landing, and applied full power. He said the engines would not develop thrust and he elected to land in a field less than 1/4 mile in front of him. Examination of the left thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully open. Both the left and right pneumatic latches were found in the unlocked position. Examination of the right thrust reverser revealed that the translator was in the deployed position, with the blocker doors fully closed. The left pneumatic latch was found in the locked position. The right pneumatic latch was found in the unlocked position. The inboard sequence latches were found about 2 inches forward of full aft travel. The thrust reverser switch was found in the 'NORMAL' position. According to Gates Lear Jet Airworthiness Directive (AD) 79-08-01, '...to preclude inadvertent thrust reverser deployment and possible loss of aircraft control....,' the following limitations apply to all gates Lear Jet Model 35, 36, 35A, 36A, aircraft equipped with Aeronca Thrust reversers. According to the AD, Section I-LIMITATION; '....Thrust Reversers must not be operated prior to takeoff...Thrust Reversers must not be used for touch and go landings...After Thrust Reversers have been deployed, a visual check of proper door stowing must be made prior to takeoff...Operational Procedures in this Thrust Reverser Supplement are mandatory.' According to Lear Jet and FlightSafety International, the procedures that are taught to Lear Jet pilots in the use of thrust reverse and spoilers during landings are; '...pilots [are] to use thrust reverse only on full stop Lear Jet landings. Pilot are trained not to deploy spoilers or thrust reverse during touch and go's or during balked landings.' The pilot-in-command of N19LH at the time of the accident, told the NTSB investigator-in-charge (IIC) that he was 'aware' of the limitations on the Aeronca Thrust Reverser and he knew that once the Thrust Reverser was deployed that he was 'committed' to land. The pilot told the IIC that he knew of the limitations and that he was committed to land.
Probable cause:
A loss of engine power as a result of the thrust reversers being deployed and subsequent inflight collision was wires. Factors in this accident were the pilot's disregard for procedures, and the improper use of the thrust reversers.
Final Report:

Crash of an Aviation Traders ATL-98 Carvair in Venetie

Date & Time: Jun 28, 1997 at 1618 LT
Registration:
N103
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Venetie - Fairbanks
MSN:
10273/4
YOM:
1943
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
3000.00
Aircraft flight hours:
7145
Circumstances:
The air cargo flight had just off loaded its cargo at a remote site. Shortly after takeoff, the number two engine begin to run rough. The engine was shut down, and the propeller feathered. During the shutdown process, a fire warning light illuminated, and fire became visible near the number 2 engine. The crew activated both banks of engine fire extinguishers, but were unable to extinguish the fire. While on approach to an off-airport emergency landing site, the number two engine fell off and ignited a brush fire. The crew made a successful landing and ran away from the airplane. The airplane continued to burn and was destroyed by fire. The number 2 engine was not recovered or located.
Probable cause:
A fire associated with the number 2 engine for undetermined reasons.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Saskatoon

Date & Time: May 29, 1997
Type of aircraft:
Operator:
Registration:
C-FOCS
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
54
YOM:
1949
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
5000.00
Circumstances:
Shortly after takeoff from Saskatoon, while in initial climb, the single engine aircraft nosed down and crashed, bursting into flames. The pilot, sole on board, was seriously injured and the aircraft was totally destroyed by impact forces and a post crash fire.
Probable cause:
Bought by Athabaska Airways four days prior to the accident, the aircraft was checked by the company's mechanics. It was determined that the loss of control was the consequence of an issue with the elevator control cables that were not installed in a properly manner by the people in charge of the maintenance.

Crash of a Learjet 35A in Great Falls

Date & Time: May 16, 1997 at 1314 LT
Type of aircraft:
Registration:
N1AH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Great Falls - Dallas
MSN:
35-398
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8700
Captain / Total hours on type:
2000.00
Aircraft flight hours:
8019
Circumstances:
The captain reported: 'Shortly after V1...there was a loss of power to the left engine....' (FAR Part 1 defines V1 as takeoff decision speed.) However, the first officer, who was the pilot flying, stated the captain retarded power on the left engine as a training exercise. The first officer stated there was no preflight discussion of emergency procedure practice. The airplane became airborne about 3,500 feet down the runway; the crew subsequently lost control of the aircraft, and it crashed to the left of the runway, and a fire erupted. The crew escaped with minor injuries. A teardown of the left engine was performed under FAA supervision at the engine manufacturer's facilities; the engine manufacturer reported that damage found during the teardown 'was indicative of engine rotation and operation at the time of impact....' Both airspeed indicator bugs were found set 9 to 11 knots below the V1 speed on the takeoff and landing data (TOLD) card. No evidence of an aircraft or engine malfunction, to include inflight fire, was found at the accident site.
Probable cause:
The captain's inadequate preflight planning/preparation, and the subsequent improper response to a simulated loss of engine power, resulting in liftoff at an airspeed below that for which sustained flight was possible.
Final Report:

Crash of a Learjet 35A in Greenville

Date & Time: Feb 27, 1997 at 1015 LT
Type of aircraft:
Operator:
Registration:
N440HM
Flight Type:
Survivors:
Yes
Schedule:
Atlanta - Greenville
MSN:
35-294
YOM:
1980
Flight number:
GRA440
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5293
Captain / Total hours on type:
202.00
Circumstances:
The pilot-in-command stated he was cleared for an ILS approach. He had to use spoilers to intercept the glideslope. The landing was extended at the outer marker as the airspeed was slowed through 200 knots. As the airspeed decreased the spoilers were retracted and the flaps were extended to 20-degrees. The airplane was drifting to the right and flaps were lowered to 40-degrees as the drift was corrected. The airplane floated and touched down long. The spoilers, and brakes were applied as well as full reverse. There was no braking due to hydroplaning. Examination of the crash site revealed the airplane went off the end of the runway, skidded through 200 feet of sod, vaulted off a 25 foot embankment, skidded across a road, and collided with a ditch.
Probable cause:
The pilot-in-command's failure to achieve the proper touchdown point on a known wet runway, resulting in a subsequent overrun and on ground collision with a ditch.
Final Report:

Crash of a Cessna 500 Citation I on Mt Balatukan: 2 killed

Date & Time: Feb 1, 1997
Type of aircraft:
Registration:
RP-C1500
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Cagayan de Oro – Butuan City
MSN:
500-0225
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Few minutes after takeoff from Cagayan de Oro Airport, while climbing to a height of 8,000 feet, the aircraft struck the slope of Mt Balatukan located about 57 km northeast of Cagayan de Oro Airport. Both pilots were killed.
Probable cause:
Controlled flight into terrain for unknown reasons.