Crash of a Britten-Norman BN-2A-21 Islander in Namatanai

Date & Time: Dec 10, 1993
Type of aircraft:
Operator:
Registration:
P2-ALL
Flight Type:
Survivors:
Yes
MSN:
448
YOM:
1975
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach, at a height of about 250 feet, the pilot selected flaps down when the aircraft went unstable, stalled and crashed short of runway threshold. The pilot was injured.

Crash of a Cessna 421A Golden Eagle I in Avignon: 2 killed

Date & Time: Nov 20, 1993
Type of aircraft:
Registration:
F-GBEX
Flight Type:
Survivors:
No
MSN:
421A-0143
YOM:
1968
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On approach to Avignon-Caumont Airport while on a positioning flight, the twin engine aircraft crashed on a road and was destroyed. Both pilots were killed.

Crash of a Rockwell Grand Commander 690A in Lansing: 2 killed

Date & Time: Sep 27, 1993 at 1123 LT
Registration:
N242TC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Lansing - Battle Creek
MSN:
690-11219
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8790
Aircraft flight hours:
4373
Circumstances:
The airplane departed in IMC conditions on an IFR flight plan. Shortly after takeoff the pilot told the departure controller he had '...a problem.' The airplane's flight path was a series of left hand turns while performing descents and ascents. Reports of engine sounds varied from high rpm to low rpm. Many witnesses reported the airplane descending out of, and climbing into, clouds. The airplane was observed in a 45° angle descent, right wing low, as it collided with trees and the ground. The on-scene investigation found an intermittent electric gyro system inverter, a broken filament on the inverter power 'out' light bulb, electrically powered gyro's rotors did not have rotational damage, and a vacuum powered attitude indicator rotor with rotational damage. The pilot's toxicology report stated 45 mg/dl of ethanol detected in his muscle tissue.
Probable cause:
The pilot-in-command not maintaining aircraft control during the intermittent operation of the electrically operated attitude gyro. Factor's associated with this accident are an fluctuating (intermittent) electrical system inverter and the pilot-in-command not performing remedial action by using the vacuum powered attitude gyro and other flight instruments once the airplane was making a series of climbs, descents, and heading changes.
Final Report:

Crash of a Swearingen SA226AC Metro II in Hartford: 2 killed

Date & Time: Aug 17, 1993 at 0225 LT
Type of aircraft:
Registration:
N220KC
Flight Type:
Survivors:
No
Schedule:
Farmingdale - Hartford
MSN:
AC-231
YOM:
1977
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4200
Captain / Total hours on type:
600.00
Aircraft flight hours:
16710
Circumstances:
On an approach to land at the destination, the second-in-command (sic) was flying the airplane. The plane touched down with the landing gear retracted, and the propeller blades contacted the runway. The sic initiated a go-around (aborted landing). Witnesses saw the airplane in a steep left bank just before impact in a river next to the airport. Propeller strikes on the runway extended 380 feet, indicating a touchdown speed of 96 knots. The last propeller strikes on the right side indicated a speed of 86 knots. The last strikes on the left side indicated a slowing propeller. Published VMC for the airplane was 94 knots. The CVR tape revealed the crew completed a descent arrival check, performed an incomplete approach briefing, and did not perform a before landing check. The CVR revealed no sound of a gear warning horn. Company personnel stated that the circuit breaker for the warning horn had been found pulled at the completion of previous flights by other crew; this was to prevent a warning horn from sounding during a high rate of descent. Both pilots were killed.
Probable cause:
Failure of the copilot (second-in-command) to follow the checklist, assure the gear was extended for landing and attain or maintain adequate airspeed (VMC); and failure of the pilot-in-command (pic) to properly supervise the flight and take sufficient remedial action.
Final Report:

Crash of a Piper PA-31-310 Navajo C in Guildford: 1 killed

Date & Time: Aug 15, 1993 at 0805 LT
Type of aircraft:
Registration:
G-SEAS
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stapleford – Southampton – Cambridge – Berlin
MSN:
31-79
YOM:
1979
Flight number:
STL819
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1493
Captain / Total hours on type:
15.00
Circumstances:
The pilot departed Stapleford on a positioning flight to Southampton. He was due to pick up passengers at Southampton and fly to Cambridge where more passengers were to be collected; from Cambridge he would fly to Berlin. Heathrow Approach frequency was fairly busy but by 0653LT, G-SEAS had been identified, and been cleared direct to Ockham not above 2,000 feet on QNH 1011 mb; this clearance was acknowledged by the pilot. The radar recording confirmed the track of STL819 to Ockham and from there the aircraft made a gentle turn onto a track of approximately 185°T; all three radars confirmed the aircraft speed as approximately 160 knots and at a level altitude of 1,500 feet amsl until a few seconds before 0705LT. At that point the aircraft started a high rate of descent with increasing speed but maintaining a fairly constant southerly track. Radar contact was lost 2.6 seconds after 0705LT. The last radar contact was within 250 metres of the crash site and at that point the aircraft was at 1,000 feet amsl, the crash site is approximately 400 feet amsl.
Probable cause:
Investigations were unable to determine the exact cause of the accident. Nevertheless, the assumption that the loss of control was the consequence of an autopilot failure was not ruled out.
Final Report:

Crash of a Cessna 550 Citation II in Southampton

Date & Time: May 26, 1993 at 0634 LT
Type of aircraft:
Registration:
G-JETB
Flight Type:
Survivors:
Yes
Schedule:
Oxford - Southampton - Eindhoven
MSN:
550-0288
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16700
Captain / Total hours on type:
850.00
Copilot / Total flying hours:
1322
Copilot / Total hours on type:
109
Aircraft flight hours:
4315
Aircraft flight cycles:
3306
Circumstances:
Cessna Citation G-JETB was to fly eight passengers from Southampton (SOU) to Eindhoven (EIN). Because G-JETB had arrived at Oxford (OXF) the previous evening, the airplane had to be ferried to Southampton early in the morning. This as a regular occurrence. The co-pilot had agreed with the airport authorities at both Oxford and Southampton that the aircraft would operate outside normal hours on the understanding that no fire cover would be provided. Following the takeoff from Oxford at 05:19 the crew contacted Brize Norton ATC and agreed a Flight Information Service. They maintained VMC for the transit at 2,400 feet QNH and called Southampton ATC on their alternate radio at 05:25 when they were approximately 30 nm from Southampton. The Southampton controller was surprised at their initial call and advised them that the airport did not open until 06:00. The crew informed him that arrangements had been made for an early arrival and the controller asked them to standby while he checked this agreement. At 05:27 he called G-JETB, informed the crew that they could land before the normal opening hours and asked them to confirm that no fire cover was required. The crew confirmed this and were then told that runway 02 was in use with a wind of 020 deg./14 kt and that there was a thunderstorm right over the airport. The crew then advised Brize Norton radar that they were going to Southampton ATC and left the Brize Norton frequency. Following a further check with Southampton they were given the 0520 weather observation: "Surface wind 040 deg/12 kt, thunderstorms, 2 oktas of stratus at 800 feet, 3 oktas of cumulonimbus at 1,800 feet, temperature 12 C, qnh 1007 mb, qfe 1006 mb, the runway is very wet." At 05:30 the controller asked the crew for the aircraft type and, after being told that it was a Citation II, told the crew that the visibility was deteriorating ("Now 2,000 metres in heavy thunderstorms" ) and cleared them to the Southampton VOR at 3,000 feet QNH. After checking that they were now IFR the controller confirmed the clearance, and the QNH of 1007 mb, and informed the crew that there was no controlled airspace and that he had no radar available to assist them. Shortly afterwards the controller advised the crew that: "Entirely at your discretion you may establish on the ILS localiser for runway 20 for visual break-off to land on runway 02." The commander accepted this offer and, within the cockpit, asked the co-pilot for the surface wind. He was informed that it was 040 degrees but that earlier they had been given 020 deg/14 kt. At 05:32 the commander had positioned on the ILS for runway 20 and began his descent; the co-pilot advised Southampton that they were established. The controller acknowledged this and again passed the QNH. Shortly afterwards he asked the crew to report at the outer marker and this message was acknowledged. At 05:33 the crew called that they were visual with the runway and the controller cleared them for a visual approach, left or right at their convenience, for runway 02. As this transmission was taking place, the commander informed his co-pilot that they would land on runway 20. The commander decided this because he could see that the weather at the other end of the runway appeared very black and he had mentally computed the tailwind component to be about 10 kt. After a confirmation request from the co-pilot to the commander, the co-pilot informed the Southampton controller that they would land on runway 20. The controller then advised them that: "You'll be landing with a fifteen knot, one five knot, tailwind component on a very wet runway" ; this was immediately acknowledged by the co-pilot with: "roger, copied thank you". The crew continued with their approach, initially at 15 kt above their computed threshold speed (VREF) of 110 kt and then at a constant VREF+10 kt. Within the cockpit the commander briefed the co-pilot that if they were too fast the co-pilot was to select flap to the takeoff position and they would go-around; they also discussed the use of the speedbrake and the commander stated that he would call for it when he wanted it. The speed at touchdown was within 5 kt of the target threshold speed and touchdown was in the vicinity of the Precision Approach Path Indicators (PAPIs), according to witnesses in the Control Tower and on the airport; the commander was certain that he had made a touchdown within the first 300 feet of the runway. The PAPIs are located 267 metres along the runway. Speedbrake was selected as the aircraft touched down and, although the commander applied and maintained heavy foot pressure on the brakes, no retardation was apparent; external observers reported heavy spray from around the aircraft. At some stage down the runway the commander stated that the brakes were not stopping them and the co-pilot called for a go-around ; the commander replied : "No we can't" as he considered that a go-around at that stage would be more dangerous. He maintained brake pressure and, in an attempt to increase distance, steered the aircraft to the right edge of the runway before trying to steer back left. Initially the aircraft nose turned to the left and the aircraft slid diagonally off the right side of the runway on to the grass. It continued across the grass for a distance of approximately 233 metres while at the same time yawing to the left. However, 90 metres beyond the end of the runway there is an embankment which forms the side of the M27 motorway and G-JETB slid down this embankment on to the motorway. The aircraft continued to rotate as it descended and came to rest, having turned through approximately 150 degrees, with its tail on the central barrier. During these final manoeuvres the aircraft collided with two cars travelling on the eastbound carriageway; the aircraft and one of the cars caught fire. During the approach of the aircraft, the airport Rescue and Fire Fighting Service (RFFS) duty officer had discussed with the duty ATC controller the imminent arrival of G-JETB. Although not all checks had been complete, the fire officer offered his two fire vehicles as a weather standby ; he did not declare his section operational but agreed with ATC that they would position themselves to the west of the runway. When the aircraft was 1/2 to 2/3 down the runway, the ATC controller considered that the aircraft would not stop in the runway available and activated the crash alarm. The fire section obtained clearance to enter the runway after G-JETB had passed their position and followed the aircraft. Assessing the situation on the move, the fire officer ordered the FIRE 2 vehicle to disperse through the crash gate to the motorway, and took his own vehicle (FIRE 1) to the edge of the embankment. On arrival, the fire section contained the fires. The occupants of the aircraft and cars escaped with minor injuries.
Probable cause:
The investigation identified the following causal factors:
- The commander landed with a reported tailwind of 15 knots which was outside the aircraft maximum tailwind limit of 10 knots specified in the Cessna 550 Flight Manual.
- The copilot did not warn the commander that he was landing with a reported tailwind component which was outside the aircraft limit.
- With a tailwind component of 10 knots, the landing distance available was less than the landing distance required.
Final Report:

Crash of a Cessna 207A Stationair 7 near Holy Cross

Date & Time: May 6, 1993 at 1530 LT
Operator:
Registration:
N70364
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Shageluk - Aniak
MSN:
207-0550
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5395
Captain / Total hours on type:
1470.00
Aircraft flight hours:
7801
Circumstances:
The pilot reported that while in cruise flight looking at birds out the left side cockpit window he observed peripherally a 'white flash' fill the right side of the forward wind screen followed immediately by an audible 'thump'. The airplane began an uncontrollable descent and yaw to the right. The engine continued to run smoothly. Advancing the engine power controls had no noticeable effect on his ability to arrest the descent. The NTSB investigator in charge visited the accident site. No evidence was found of a bird strike. The accident site was surrounded by tall (white) birch trees. The pilot stated that he was not sure what he struck and that it could have been a tree.
Probable cause:
The failure of the pilot in command to maintain the proper altitude. The trees were a factor in the accident.
Final Report:

Crash of a Mitsubishi MU-2B-35 Marquise near Nome

Date & Time: Jan 5, 1993 at 2021 LT
Type of aircraft:
Operator:
Registration:
N900YH
Flight Type:
Survivors:
Yes
Schedule:
Bethel - Nome
MSN:
584
YOM:
1973
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11150
Captain / Total hours on type:
512.00
Aircraft flight hours:
6725
Circumstances:
After making a refueling stop, the pilot took off at night and was cruising at FL200. After about 30 minutes of flight, the right engine fuel filter bypass warning light illuminated. About 2 minutes later, the same warning light for the left engine illuminated. Soon thereafter the right engine, then the left engine, lost power. The pilot made a forced landing on a moving ice pack in the Bering sea, which resulted in substantial damage. Ice was found in the engine and main fuel screens. Significant amounts of water and/or ice were found in 3 tanks, which had been refueled before takeoff. A higher than normal amount of water was also found in the fuel sample taken from the nozzle of the refueling tanker. The flight manual required that an approved ice inhibitor be added to the fuel, if not premixed. Fuel at the refueling stop was not premixed and the pilot had no icing inhibitor (prist) with him on this flight. He did not drain fuel from the tanks during preflight, since the temperature was so cold he feared the drain might freeze open.
Probable cause:
Fuel starvation due to improper refueling procedures by the fbo personnel, inadequate preflight by the pilot, and resultant ice in the fuel, which blocked fuel flow to the engines. A factor was the lack of suitable terrain for a forced landing.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in South Bimini

Date & Time: Jan 2, 1993 at 0945 LT
Registration:
N4107V
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - South Bimini
MSN:
31-8253010
YOM:
1982
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances upon landing at South Bimini Airport. The pilot, sole on board, was uninjured.

Crash of a Cessna 414A Chancellor in Wels: 3 killed

Date & Time: Dec 15, 1992 at 1758 LT
Type of aircraft:
Registration:
D-IHKB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wels – Linz – Bratislava
MSN:
414A-0269
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1421
Aircraft flight hours:
1725
Aircraft flight cycles:
1576
Circumstances:
The twin engine aircraft departed Wels Airport on a short positioning flight to the nearest airport of Linz-Hörsching before continuing to Bratislava. Weather conditions were poor with visibility down to 100 metres due to fog and an RVR of 325 metres for runway 27. After takeoff from runway 27, the aircraft struck tree tops located 1,125 metres past the runway end, lost height and crashed 300 metres further, bursting into flames. The aircraft was destroyed by fire and all three occupants were killed.
Probable cause:
It was determined that several instruments were not properly set for takeoff. The pilot did not choose the correct runway and the visibility was below minimums. The pilot did not have a licence allowing him to fly in IMC conditions.