Crash of an Airbus A330-321 in Toulouse: 7 killed

Date & Time: Jun 30, 1994 at 1741 LT
Type of aircraft:
Operator:
Registration:
F-WWKH
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Toulouse - Toulouse
MSN:
42
YOM:
1993
Flight number:
BGA129
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
7713
Captain / Total hours on type:
345.00
Copilot / Total flying hours:
9558
Copilot / Total hours on type:
137
Aircraft flight hours:
360
Circumstances:
An Airbus A330-300 aircraft crashed during a test flight at the Toulouse-Blagnac Airport in France, killing all seven on board. The test flight was part of the preparation required to certify the autopilot, on this Airbus A330 equipped with Pratt and Whitney engines, to category III standards. The first part of the test flight was completed successfully when the aircraft landed on runway 15L. A 180 degree turn was made for takeoff from runway 33R. The second takeoff was to be performed under conditions similar to those of the first takeoff. For this test however, the autopilot would incorporate the modification under study. The takeoff was performed by the co-pilot with TOGA (Takeoff Go Around) power instead of Flex 49, a lower power setting which was specified in the test procedure. Rotation was positive and pitch input was stopped when the attitude changed from 12 to 18 degrees nose-up. Within 5 seconds after takeoff several attempts to engage the autopilot were unsuccessful. After it was engaged, activation was delayed by two seconds because the first officer was exerting a slight nose down input on the side stick. The aircraft, still trimmed at 2.2 degrees nose-up, pitched up to reach 29 degrees and the speed had decreased to 145 knots. The captain meanwhile reduced thrust on the no. 1 engine to idle and cut off the hydraulic system in accordance with the flight test order. Immediately after it activated, the autopilot switched to altitude acquisition mode. The altitude had been set at 2000 feet on the previous flight phase. This caused the pitch attitude to increase to 32 degrees in an attempt to reach 2000 feet. The speed decreased further to 100 knots, whereas the minimum control speed is 118 kts. Roll control was lost and the captain reduced no. 2 engine thrust to idle to recover symmetry on the roll axis. Bank and pitch attitudes had reached 112 degrees left and -43 degrees resp. before the pilot managed to regain control. It was however too late to avoid ground impact at a pitch attitude of around -15 degrees.
Probable cause:
At the present stage of its work, the commission estimates that the accident can be explained by a combination of several factors none of which, taken separately, would have led to an accident.
The initial causes are primarily related to the type of the test and its execution by the crew during the last takeoff:
1) choice of maximum power (TOGA) instead of Flex 49;
2) very aft CG for the last takeoff;
3) trim set in the takeoff range, but in too high a nose-up position;
4) selected altitude of 2000 feet;
5) imprecise and late definition of the test to be conducted and the tasks to be performed by the captain and first officer, respectively;
6) positive and very rapid rotation executed by the first officer;
7) the captain was busy with the test operations to be performed immediately after take off (engagement of the autopilot, reduce thrust on the engine and cut off the blue hydraulic system) which temporarily placed him outside the control loop;
8) in addition the absence of pitch attitude protection in the autopilot altitude acquisition mode played a significant role.
The following factors also contributed to the accident:
1) The inability of the crew to identify the mode in which the autopilot was placed;
2) the confidence of the crew in the expected reactions of the aircraft;
3) the late reaction from the flight test engineer when faced with a potentially hazardous change in parameters (speed in particular);
4) the time taken by the captain to react to an abnormal situation.

Crash of an Antonov AN-26 in Playa Baracoa

Date & Time: Dec 31, 1993
Type of aircraft:
Operator:
Registration:
CU-T1240
Flight Type:
Survivors:
Yes
Schedule:
Playa Baracoa - Playa Baracoa
MSN:
112 10
YOM:
1981
Country:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was performing a brake test when control was lost. The aircraft veered off runway and came to rest. There were no injuries but the aircraft was damaged beyond repair. The exact date of the mishap remains unknown, somewhere in 1993.

Crash of an Embraer EMB-110P2 Bandeirante in Bangkok

Date & Time: Oct 25, 1993
Operator:
Registration:
HS-SKL
Flight Type:
Survivors:
Yes
Schedule:
Bangkok - Bangkok
MSN:
110-229
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was engaged in a local post maintenance test flight at Bangkok-Don Mueang Airport. After takeoff, while in initial climb, the crew encountered technical problems with the left main gear. After being cleared by ATC, the crew decided to return for an emergency landing and made a turn then completed a belly landing. The aircraft came to rest on the main runway and was damaged beyond repair. Both pilots escaped uninjured.
Probable cause:
It was determined that a an element of the left main landing gear strut failed during initial climb, causing the loss of several elements of the landing gear.

Crash of a Canadair RegionalJet CRJ-100ER in Byers: 3 killed

Date & Time: Jul 26, 1993 at 1352 LT
Operator:
Registration:
C-FCRJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita - Wichita
MSN:
7001
YOM:
1991
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3836
Captain / Total hours on type:
875.00
Aircraft flight hours:
771
Aircraft flight cycles:
800
Circumstances:
The crew was performing a lateral and directional stability test. Changes from earlier tests combined new leading edge fairing, new flap setting, lower reference airspeed, and trial settings for the stall protection system (shaker and pusher). Engineers had briefed the crew data would be sufficient if the steady heading sideslip (shss) maneuver ended at a 15° sideslip, or at onset of stall warning; crew agreed to end at stall warning. During the test the capt continued past stall warning to 21° sideslip at full rudder. The airplane rolled rapidly through 360 deg° and entered a deep stall. The copilot attempted to deploy the anti-spin chute. However, all the chute system cockpit switches were not properly preset; instead of assisting recovery, the chute parted from the airplane. Full control was not regained before impact. The chute system design allowed deployment of the chute even when the hyd lock switch was in the unlocked position and the hooks clasping the chute shackle to the airframe were open. System tested ok before flight. All three crew members were killed.
Probable cause:
The captain's failure to adhere to the agreed upon flight test plan for ending the test maneuver at the onset of prestall stick shaker, and the flightcrew's failure to assure that all required switches were properly positioned for anti-spin chute deployment. A factor which contributed to the accident was the inadequate design of the anti-spin chute system which allowed deployment of the chute with the hydraulic lock switch in the unlocked position. (When in the unlocked position, the hooks clasping the chute shackle to the airframe are open).
Final Report:

Crash of an Ilyushin II-114 in Moscow: 7 killed

Date & Time: Jul 5, 1993
Type of aircraft:
Operator:
Registration:
RA-54001
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Moscow - Moscow
MSN:
01-03
YOM:
1989
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft was engaged in a local test flight, carrying nine engineers and pilots. Shortly after takeoff from Moscow-Zhukovsky Airport, while climbing to a height of 45 metres, the right propeller autofeathered. The aircraft started to roll left and right then reached a critical angle of attack. Out of control, it stalled and crashed 400 metres past the runway end, bursting into flames. Two people were seriously injured while seven others were killed. The aircraft was supposed to perform a series of five 7-minutes flights to test the noise from ground. At the time of the accident, the total weight of the aircraft was near the limit.
Probable cause:
It was determined that the right engine autofeathered immediately after lift-off due to an electronic malfunction.

Crash of a De Havilland DHC-3 Otter in Villeneuve: 2 killed

Date & Time: May 22, 1993 at 0922 LT
Type of aircraft:
Operator:
Registration:
C-GKPB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Villeneuve - Villeneuve
MSN:
274
YOM:
1958
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine aircraft was engaged in a post maintenance test flight, carrying one engineer and two pilots. Shortly after takeoff from Villeneuve Airport, while in initial climb, the aircraft started to pitch up and down then lost height and crashed. The passenger was seriously injured while both pilots were killed, among them Billy Bourque, owner of Loon Air.
Probable cause:
It was determined that the loss of control was the consequence of an error on part of the ground personnel in charge of the maintenance as the controls to the left aileron had been mis-rigged.

Crash of a Douglas DC-6B off Cozumel: 3 killed

Date & Time: May 15, 1993 at 0932 LT
Type of aircraft:
Registration:
XA-SEA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cancún - Cancún
MSN:
43825
YOM:
1953
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
920
Aircraft flight hours:
38447
Circumstances:
The four engine aircraft departed Cancún Airport at 0922LT on a post maintenance check flight. The crew consisting of three engineers and two pilots was supposed to make several engine tests and verification in flight. The aircraft departed Cancún and continued to the south to Cozumel where it was supposed to make an approach (no landing planned) before returning to Cancún. While approaching Cozumel Island, the crew encountered poor weather conditions with low clouds and rain falls. In limited visibility, the aircraft descended below the prescribed altitude of 2,000 feet until it crashed in the sea some 22 km north of Cozumel Airport. The copilot and a passenger were seriously injured while the captain was killed. Two other passengers were not recovered.
Probable cause:
It was determined that the crew performed an altitude loss operation, in low visibility conditions, with an exaggerated descent angle considering the flight level (2,000 feet) over water, not allowing space for the recovery of the aircraft, until impacting the water surface.
Final Report:

Crash of a Douglas DC-9-15 off Margarita Island: 11 killed

Date & Time: Apr 2, 1993
Type of aircraft:
Operator:
Registration:
YV-03C
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Caracas - Caracas
MSN:
47000
YOM:
1967
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
The aircraft departed Caracas-Maiquetía-Simon Bolivar on a post maintenance test flight, carrying eight engineers and technicians and three crew members. Twenty-eight minutes into the flight, the crew started the test program when nine minutes later, the pilot was able to send a brief mayday message but its content remains unclear. The aircraft entered an uncontrolled descent and crashed in the sea 16 km off Margarita Island. The aircraft disintegrated on impact and few debris were found floating on water while the majority of the aircraft sank to a significant depth and was not recovered.
Probable cause:
Due to lack of evidences, the exact cause of the accident could not be determined with certainty.

Crash of a Boeing 737-3Z6 in Muang Khon Kaen: 6 killed

Date & Time: Mar 30, 1993
Type of aircraft:
Operator:
Registration:
33-333
Flight Type:
Survivors:
No
Schedule:
Bangkok - Muang Khon Kaen
MSN:
24480
YOM:
1989
Flight number:
KAT333
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
During the days prior to the accident, various problems with the pitch-trim system and the horizontal stabilizers were noticed and reported. Repairs were conducted by technicians from the Royal Thai Air Force but apparently, not according to the Boeing published procedures, so a Boeing engineer was dispatched in Thailand to proceed to controls and tests. On approach to Muang Khon Kaen Airport, the aircraft started to pitch up and down then stalled. The crew increased engine power and regained control for few seconds when the aircraft stalled a second time few seconds later. The crew elected to regain control and to reduce the rate of descent when the aircraft entered an uncontrolled descent and crashed in a rice paddy field located few km from the airport. The aircraft was destroyed and all six occupants were killed. The aircraft has the dual registration 33-333 (military) and HS-TGQ (civil).
Probable cause:
The loss of control occurred when the crew retracted the flaps and increased engine power, probably following a technical problems with the pitch-trim control system. Investigations were unable to determine the exact cause of the pitch control system malfunction.

Crash of a Lockheed L-382E-16C Hercules at Dobbins AFB: 7 killed

Date & Time: Feb 3, 1993 at 1327 LT
Type of aircraft:
Operator:
Registration:
N130X
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Dobbins AFB - Dobbins AFB
MSN:
4412
YOM:
1971
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
7658
Captain / Total hours on type:
1260.00
Aircraft flight hours:
6708
Circumstances:
The aircraft was designed and used as the company's engineering test bed. An evaluation of the fly-by-wire rudder actuator and ground minimum control speed (vmcg) was being conducted. During the final hi-speed ground test run, the aircraft abruptly veered left and became airborne. It entered a left turn, climbed to about 250 feet, departed controlled flight and impacted the ground. Investigation revealed a design feature in the rudder actuator that removes hydraulic pressure within the actuator if the rudder position commanded by the pilot exceeded the actual rudder actuator position for a specified time, and the rudder aerodynamically trails. The actuator previously disengaged in flight. The company did not conduct a system safety review of the rudder bypass feature and its consequences to all flight regimes, nor of the vmcg test. The flight test plan specified that engine power be retarded if the rudder became ineffective. Neither pilot had received training as an experimental test pilot. The company allowed experimental flight tests at a confined, metropolitan airport. All seven occupants were killed.
Probable cause:
Disengagement of the rudder fly-by-wire flight control system resulting in a total loss of rudder control capability while conducting ground minimum control speed tests. The disengagement was a result of the inadequate design of the rudder's integrated actuator package by its manufacturer; the operator's insufficient system safety review failed to consider the consequences of the inadequate design to all operating regimes. A factor which contributed to the accident was the flight crew's lack of engineering flight test training.
Final Report: