Crash of a Beechcraft F90 King Air in Lynchburg

Date & Time: Nov 24, 2000 at 1151 LT
Type of aircraft:
Registration:
N94U
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lynchburg - Lynchburg
MSN:
LA-124
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
250.00
Aircraft flight hours:
6788
Circumstances:
The pilot was conducting a post-maintenance test flight. An overhauled engine had been installed on the right side of the airplane, and both propeller assemblies had been subsequently re-rigged. Ground checks were satisfactory, although the right engine propeller idled 90-100 rpm higher than the left engine propeller. Test flight engine start and run-up were conducted per the checklist, with no anomalies noted. Takeoff ground roll and initial climb were normal; however, when the airplane reached about 100 feet, it stopped climbing and lost airspeed. The pilot could not identify the malfunction, and performed a forced landing to rough, hilly terrain. Upon landing, the landing gear collapsed and the engine nacelles were compromised. The airplane subsequently burned. Post-accident examination of the airplane revealed that the propeller beta valves of both engines were improperly rigged, and that activation of the landing gear squat switch at takeoff resulted in both propellers going into feather. The maintenance personnel did not have rigging experience in airplane make and model. As a result of the investigation, the manufacturer clarified maintenance manual and pilot handbook procedures.
Probable cause:
Improper rigging of both propeller assemblies by maintenance personnel, which resulted in the inadvertent feathering of both propellers after takeoff. Factors included a lack of rigging experience in airplane make and model by maintenance personnel, unclear maintenance manual information, and unsuitable terrain for the forced landing.
Final Report:

Crash of a Canadair CL-604-2B16 Challenger in Wichita: 3 killed

Date & Time: Oct 10, 2000 at 1452 LT
Type of aircraft:
Operator:
Registration:
C-FTBZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Wichita - Wichita
MSN:
5991
YOM:
1994
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6159
Captain / Total hours on type:
189.00
Copilot / Total flying hours:
6540
Copilot / Total hours on type:
1
Aircraft flight hours:
1226
Circumstances:
On October 10, 2000, at 1452 central daylight time, a Canadair Challenger CL-600-2B16 (CL604) (Canadian registration C-FTBZ and operated by Bombardier Incorporated) was destroyed on impact with terrain and postimpact fire during initial climb from runway 19R at Wichita Mid-Continent Airport (ICT), Wichita, Kansas. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an experimental test flight. The pilot and flight test engineer were killed. The copilot was seriously injured and died 36 days later.
Probable cause:
The pilot’s excessive takeoff rotation, during an aft center of gravity (c.g.) takeoff, a rearward migration of fuel during acceleration and takeoff and consequent shift in the airplane’s aft c.g. to aft of the aft c.g. limit, which caused the airplane to stall at an altitude too low for recovery. Contributing to the accident were Bombardier’s inadequate flight planning procedures for the Challenger flight test program and the lack of direct, on-site operational oversight by Transport Canada and the Federal Aviation Administration.
Final Report:

Ground fire of a Boeing 767-2B7ER in Philadelphia

Date & Time: Sep 22, 2000
Type of aircraft:
Operator:
Registration:
N654US
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
25225/375
YOM:
1991
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft experienced an uncontained failure of the high pressure turbine stage 1 disk in the No. 1 engine during a high-power ground run for maintenance. Because of a report of an in-flight loss of oil, US Airways mechanics had replaced a seal on the n°1 engine’s integral drive generator and were performing the high-power engine run to check for any oil leakage. For the maintenance check, the mechanics had taxied the airplane to a remote taxiway on the airport and had performed three runups for which no anomalies were noted. During the fourth excursion to high power, at around 93 percent N1 rpm, there was a loud explosion followed by a fire under the left wing of the airplane. The mechanics shut down the engines, discharged both fire bottles into the No. 1 engine nacelle, and evacuated the airplane. Although both fire bottles were discharged, the fire continued until it was extinguished by airport fire department personnel. The aircraft was damaged beyond repair.

Crash of a Beechcraft A60 Duke in Halle-Oppin

Date & Time: Aug 2, 2000 at 1424 LT
Type of aircraft:
Operator:
Registration:
D-IMEI
Flight Type:
Survivors:
Yes
Schedule:
Halle-Oppin - Halle-Oppin
MSN:
P-145
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a local test flight at Halle-Oppin Airport. For unknown reasons, it belly landed and came to rest. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-46-350P Malibu Mirage in Lytchett Matravers

Date & Time: Jul 7, 2000 at 1555 LT
Registration:
N44DN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bournemouth - Bournemouth
MSN:
46-22116
YOM:
1990
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10481
Captain / Total hours on type:
14.00
Circumstances:
The aircraft was undergoing a shakedown flight after having completed a 100 hr maintenance inspection and other engineering work at Bournemouth Airport. The pilot was not the owner of the aircraft, but had been requested to carry out the shakedown flight. There was no technical log available prior to the flight which could have indicated the quantity of fuel remaining on board, or when the aircraft was previously refuelled and the subsequent flight times. The pilot recalled that the fuel tank gauges showed the aircraft had 22 gall US in the left wing and 40 gall US in the right wing, a total fuel contents of 62 gall US. The Aircraft Flight Manual indicates that the maximum allowable lateral fuel imbalance is 10 gall US. The aircraft started up at 1448 hrs and taxied for departure from Runway 26. The right tank was selected for take off and the first part of the flight. The aircraft climbed to FL180 and the required engine checks were carried out satisfactorily. As the aircraft was being turned around in order to return to Bournemouth, the pilot recalled that the right fuel quantity indicator steadily dropped to zero. This caused him little concern at the time as the left fuel tank had only been selected for part of the taxi out. The aircraft was also fitted with a digital 'fuel endurance remaining' indicator, which apparently indicated 'one hour' fuel endurance. Descent was commenced and the aircraft was transferred to Bournemouth Approach control in order to position it on radar for an ILS approach to Runway 08. At this time, the pilot recalled that the fuel flow and rpm indicators began to fluctuate, so he selected the left fuel tank to feed to the engine. The aircraft was given radar vectoring and the pilot requested a turn to avoid a cloud build up before becoming established on the ILS. The radar controller indicated that the aircraft had become established on the localiser at a range of 25 nm, in the descent to 3,000 feet amsl. At about ten miles from touchdown the engine fuel flow and RPM again fluctuated. The pilot reselected the right fuel tank but the engine did not recover. Reselecting the left tank restored power briefly but then the engine failed again. The pilot turned the aircraft to the left off the ILS and attempted to identify suitable sites for a forced landing. An open field with an uphill gradient was selected, the landing gear and full flap were selected. However, the aircraft touched down further into the field than the pilot would have wished. The touchdown was smooth but the pilot could not stop the aircraft before it ran into the far boundary hedge. The left wing was severely damaged during the impact sequence. There was no fire and the three occupants vacated the aircraft by the normal means, having sustained only minor injuries.
Probable cause:
The history of the aircraft's movements was traced from ATC records at the various airfields visited. It was established that the aircraft (piloted by its owner) had operated a flight from Rome-Ciampino to Southend, landing at Southend at 2016 hrs on 21 June 2000. The aircraft was then refuelled to full tanks with 326 litres of Avgas 100LL on 23 June, prior to departure at 1425 hrs for Bournemouth, where it arrived at 1521 hrs. The aircraft then operated four sectors on two round trips between Bournemouth and Exeter Airports between 23 June and 25 June. These totalled 1 hour 47 minutes airborne flight time. The aircraft then underwent its maintenance programme and did not fly again until the accident flight. The digital fuel quantity/endurance indication relied on being reset at the time of a refuelling and subsequently used engine fuel flow to continuously recalculate remaining endurance. The aircraft's owner indicated that the instrument had been reset at the time of the previous refuelling, but was not intended to accurately monitor fuel flow during prolonged ground operations. The aircraft's total fuel tank capacity was 455 litres/120 gall US. From the aircraft's performance information, the cruise fuel flow at normal cruise power was around 69 litres per hour (18 gall US per hour) at 20,000 feet cruise altitude. From the movement history, it is known that the aircraft had been airborne for a total of 2.72 hours, at somewhat less than optimum cruise altitudes. At least 188 litres of fuel would therefore have been consumed from the 455 litres on board at the time of departure from Southend on 23 June, leaving a total of 267 litres (70 gall US) of that fuel on board. Additional fuel consumption would also have occurred during taxying before and after each flight sector (10 occasions in all) and it is known that an engine run of at least 30 minutes duration also took place during the maintenance period. It is therefore likely that all of the taxi and ground running operations would have totalled more than 1.5 hours duration. The owner estimated that some 96 gall US of fuel was consumed during the five sectors flown after the previous refuelling to full tanks (120 gall US) at Southend. Thus, it is likely that the aircraft had considerably less than the pilot's recollection of 62 gall US on board at the time of departure on the accident flight.
Final Report:

Crash of a Kawasaki C-1A off Shimano: 8 killed

Date & Time: Jun 27, 2000
Type of aircraft:
Operator:
Registration:
88-1027
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yonago AFB - Yonago AFB
MSN:
8027
Location:
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The crew (four pilots and four technicians) departed Yonago-Miho AFB on a post maintenance local flight. After several circuits, while in cruising altitude, the aircraft entered an uncontrolled descent and crashed in the sea off Shimano. All eight occupants were killed.

Crash of a Douglas C-47B-DK in Mexico City

Date & Time: Feb 3, 2000
Operator:
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mexico City - Mexico City
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Mexico City-Benito Juarez Airport on a local post maintenance test flight. After takeoff, while in initial climb, both engines lost power simultaneously. The crew attempted an emergency landing on a soccer field when the aircraft crash landed near a motorway. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Piper PA-60 Aerostar (Ted Smith 600) off Avalon: 1 killed

Date & Time: Nov 21, 1999 at 1015 LT
Registration:
N97CC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fullerton - Fullerton
MSN:
60-0154-068
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1710
Captain / Total hours on type:
951.00
Aircraft flight hours:
4199
Circumstances:
The pilot/owner was performing a post maintenance check flight about 20 miles off shore. He was receiving visual flight advisories from a terminal radar approach facility while in level flight about 4,900 feet msl. Subsequently, the airplane started slowing then descending in a right spiral, and radar contact was lost about 1,000 feet msl. The pilot's body was recovered from the ocean. According to the autopsy report, the pilot had experienced sudden cardiac death secondary to an acute myocardial infarction due to atherosclerotic coronary artery disease. Tramadol, a painkiller not approved by the FAA for flight, was detected in a drug screen and may have masked the chest pain.
Probable cause:
The pilot's in-flight loss of control due to physical incapacitation from sudden cardiac death secondary to an acute myocardial infarction.
Final Report:

Crash of a De Havilland DHC-3 Otter in Long Haul Lake: 1 killed

Date & Time: Jun 25, 1999 at 1320 LT
Type of aircraft:
Operator:
Registration:
C-FIFP
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
73
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
23960
Circumstances:
The Blue Water Aviation Services seaplane departed from Long Haul Lake, Manitoba, with a pilot and an aviation maintenance engineer on board. Shortly after take-off, at 1320 central daylight savings time, the aircraft's engine abruptly lost power. The pilot's attempts to restart the engine were unsuccessful, and the aircraft descended into a stand of trees and struck the ground. The engineer suffered fatal injuries, and the pilot was seriously injured. The aircraft was destroyed by impact forces.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The most likely accident scenario during the second take-off is that water contamination migrated from the centre fuel tank to the engine, resulting in a loss of engine power.
2. The engine stopped at a point from which there was insufficient time for the engine to restart, nor from which a safe landing could be made.
3. Indications of water contamination were found in the fuel system after the occurrence; however, the source(s) of the water contamination could not be identified.
Other Findings:
1. Examination of the aircraft and testing of the engine and components did not identify any pre-occurrence structural, mechanical, or electrical defects or malfunctions that would have
contributed to this occurrence.
2. The post-crash fire in the carburettor most likely resulted from uncontaminated fuel brought forward by the windmilling engine and the pilot's efforts to clear contamination from the fuel
system.
3. The pilot's use of his shoulder harness likely prevented more serious injuries during the impact sequence.
4. The engineer's injuries likely would have been less severe had he been using both his seat belt and shoulder harness.
5. The pilot was certified and qualified for the flight.
6. The aircraft's weight and centre of gravity were within approved limits.
7. The aircraft's records indicated that the aircraft had been certified and maintained in accordance with existing regulations.
8. The aircraft's engine power loss during the first attempted take-off was likely due to water contamination in the fuel.
Final Report:

Crash of a Beriev BE-103 in Straubing: 1 killed

Date & Time: Apr 29, 1999 at 1833 LT
Type of aircraft:
Registration:
RA-03002
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Straubing - Straubing
MSN:
30 02
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
A testflight for the purpose of vibration measurements on the propellers was to be carried out with the a.m. aircraft. The Beriev BE103 is the prototype of a 6 seater, twin engine amphibious aircraft of russian design. It was powered by two piston engines Teledyne Continental IO-360 E5 which operated hydraulic variable pitch propellers. In the course of the russian type certification the vibration behavior and the stiffness of the propeller blades had to be proven. Therefore a test propeller, fitted with wire strain gauges was attached to the L/H engine at the propeller manufacturer’s facilities in Straubing. The transducers and transmitters were fitted instead of the spinner by means of special brackets. The data recording system was installed in the aircraft’s cabin. As during the testflights a maximum of 105% of the maximum allowable rpm had to be achieved the L/H propeller governor was adjusted to 2940 rpm. Furthermore the R/H propeller and governor were changed from prototypes to the serial components. After these modifications several engine test runs were carried out for calibration of the test equipment and data recording. The testflight was recorded on a camcorder. The film showed that the pilot in command taxied to the far end of the 940 m long pavement runway, adjusted the engines while standing and thereafter commenced his take-off run which should have been approx. 300 m long with view to the aircraft weight according to information gained from the a/c manufacturer. The a/c, however, taxied far beyond the ½ marking of the runway, rotated fairly long and went airborne after approx. 700 m with a high angle of attack. After gaining 10 to 15 m of altitude the pilot in command retracted the landing gear. Right after that the a/c entered a shallow descend in a nose-up attitude and turned to the left before it left the camera view some seconds before the impact. During the entire flight a constant and normal engine noise was audible. Approx. 600 m behind the runway end the aircraft hit the bank of a street and caught fire. The pilot in command was fatally injured, the aircraft was destroyed by the impact and the post impact fire.
Probable cause:
The accident was caused by the pilot in command trying to depart at an extremely reduced power setting and not aborting the take-off in time. Technical causes were not determined. The wrong power setting was related to a misinterpretation of the function and procedures in connection with the constant speed propeller system. Although these are part of the basic knowledge of a pilot on aircraft of this category they were explained to him by employees of the propeller manufacturer and the aircraft manufacturer’s test flight engineer as part of the preflight briefing. With a high probability the pilot did not understand these explanations in all details. The service of an interpreter was refused by him. The planned testflights wouldn’t have led to a power reduction when accomplished properly.
Final Report: