Crash of a Beechcraft A90 King Air in Montpellier: 3 killed

Date & Time: Dec 24, 2004 at 0933 LT
Type of aircraft:
Operator:
Registration:
F-GVRM
Flight Type:
Survivors:
No
Schedule:
Montpellier - Montpellier
MSN:
LJ-121
YOM:
1966
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12184
Captain / Total hours on type:
2610.00
Copilot / Total flying hours:
256
Copilot / Total hours on type:
6
Aircraft flight hours:
6872
Aircraft flight cycles:
6816
Circumstances:
The crew departed Montpellier-Méditerranée Airport at 0802LT for a local training flight with TRI, one TRE and one pilot under supervision. Following a touch and go on runway 31R, the instructor decided to reduce the power on the right engine and to perform a low pass over the runway. Then the aircraft turned to the left, lost height, rolled to the left and crashed in a pond located to the right of the runway. The aircraft was destroyed and all three occupants were killed.
Probable cause:
The accident was the result of the crew losing control of the aircraft after a go-around. It is likely that this was the result of inadequate management of the flight controls while performing a one engine go-around and a too late a reaction from the examiner (TRE). The examiner's recent lack of experience in instruction on BE90 and his right-front position may have contributed to the accident. No technical anomalies was found on the aircraft and the loss of control occurred at low altitude.
Final Report:

Crash of a Cessna 421A Golden Eagle I in Denver: 3 killed

Date & Time: Dec 17, 2004 at 1522 LT
Type of aircraft:
Registration:
N421FR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Denver - Denver
MSN:
421A-0069
YOM:
1968
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12000
Copilot / Total flying hours:
414
Copilot / Total hours on type:
31
Aircraft flight hours:
2666
Circumstances:
The pilot's father had just purchased the airplane for his daughter, and she was receiving model-specific training from a contract flight instructor. Her former flight instructor was aboard as a passenger. The engines were started and they quit. They were restarted and they quit again. They were started a third time, and the airplane was taxied for takeoff. Shortly after starting the takeoff roll, the pilot reported an unspecified engine problem. The airplane drifted across the median and parallel runway, then rolled abruptly to the right, struck the ground, and cartwheeled. The landing gear was down. Neither propeller was feathered. Disassembly of the right engine and turbocharger revealed no anomalies. Disassembly and examination of the left engine and turbocharger revealed the mixture shaft and throttle valve in the throttle and fuel control assembly were jammed in the idle cutoff and idle rpm positions, respectively. Manifold valve and fuel injector line flow tests produced higher-than-normal pressures, indicative of a flow restriction. Disassembly of the manifold valve revealed the needle valve in the plunger assembly was stuck in the full open position, collapsing the needle valve spring. A scribe was used to free the needle valve, and the manifold valve and fuel injector lines were again flow tested. The result was a lower pressure. Plunger disassembly revealed the threads had been tapped inside the retainer and metal shavings were found between the retainer and spring. The Teledyne Continental Motor (TCM) retainer has no threads. GPS download showed that 2,698 feet had been covered between the start of the takeoff roll and the attainment of rotation speed. Maximum speed attained was 132 mph. Computations indicated distance to clear a 50-foot obstacle was 2,000 feet, distance to clear a 50-foot obstacle (single engine) was 2,600 feet, and accelerate-stop distance was 3,000 feet.
Probable cause:
Loss of engine power due to fuel starvation, and the instructor's failure to maintain aircraft control. Contributing factors were a partially blocked fuel line resulting in restricted fuel flow, the instructor's failure to perform critical emergency procedures, and his failure to abort the takeoff in a timely manner.
Final Report:

Crash of a Let L-410UVP-E20 in Kilimanjaro

Date & Time: Nov 17, 2004 at 0809 LT
Type of aircraft:
Operator:
Registration:
5H-PAC
Flight Type:
Survivors:
Yes
Schedule:
Kilimanjaro - Kilimanjaro
MSN:
92 27 11
YOM:
1992
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
4000.00
Circumstances:
The aircraft was on a base training flight at Kilimanjaro International Airport. At 0410 hrs it was cleared to the local flying area for upper air works, followed by VOR/ILS approaches to runway 09 via NDB KB. 5H-PAC took off and proceeded to the local flying area where the crew members did upper air works for about 30 minutes. According to the commander, these included clean and dirty stalls, level flights at different speeds, 45 degree turns left and right and exercises on unusual attitudes. Subsequent to these they returned to the airport via NDB KB for ILS approach to runway 09. They carried out a missed approach and proceeded to join RH circuits for touch-and-go operations on runway 09. The last operations before the accident was simulated engine failure after take off followed by single engine overshoot, this time using runway 27. This was approved and the commander was reminded that the surface wind was 090 degrees 08 knots. The aircraft turned left and positioned on right base for runway 27. It was subsequently given a landing clearance. The weather at the material time was fine with temperature 23 degrees Celsius. The controller, who was handling the flight, said that the final approach was perfect. The landing gear was down. The aircraft passed the threshold of runway 27 at about 70 feet above the ground and continued to flare on a straight and level attitude with the landing gear retracted. It continued in this attitude for a distance of about one and a half kilometers down the runway subsequent to which it drifted off the runway to the right. The controller asked the pilot to explain his intentions. There was no reply. Instead, the aircraft was observed to yaw violently as it drifted further to the right. Moments later, it impacted the ground on a grass hedge and skidded along the width of taxiway Y before it came to rest. The commander said that he repossessed the controls immediately when the aircraft started yawing but there was no time effect recovery. There was fuel spillage but fire did not break out. The two pilots, who had not put on their shoulder straps, sustained facial injuries.
Probable cause:
Given that the aircraft was practicing a single engine overshoot, the pilot appears to have descended too low for safe recovery. The landing gear should also have been retracted after power had been applied and positive climb achieved. The standard single engine overshoot procedure was not applied.
Final Report:

Crash of a Dornier DO228-201 in Siglufjörður

Date & Time: Jun 23, 2004 at 1941 LT
Type of aircraft:
Operator:
Registration:
TF-ELH
Flight Type:
Survivors:
Yes
Schedule:
Sauðárkrókur - Siglufjörður
MSN:
8070
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8400
Captain / Total hours on type:
2345.00
Copilot / Total flying hours:
1117
Copilot / Total hours on type:
253
Circumstances:
Following an uneventful passenger flight from Reykjavik to Sauðárkrókur, the crew decided to fly to Siglufjörður Airport to perform a competence control flight for this airfield. On approach in good weather conditions (visibility over 10 km with clouds at 1,500 feet), the captain disconnected the GPWS system to avoid repetitive alarms. After landing on runway 07, he attended to perform a touch-and-go so he increased engine power and took off. During initial climb, the landing gears were raised and the crew made a right hand turn circuit at an altitude of 500 feet. Following a second approach to runway 07, the aircraft landed on its belly and slid for 280 metres before coming to rest. Both pilots evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Belly landing after the crew failed to follow the approach checklist and failed to lower the landing gear for a second touch-and-go manoeuvre. The following contributing factors were identified:
- The crew failed to check that the three green lights were ON,
- The aircraft was unstable on final approach,
- The captain took over control without knowing how to proceed for the approach,
- The presence of birds in the vicinity of the runway disturbed the crew,
- The landing gear alert system was not properly set,
- The right hand circuit was completed at a low altitude of 500 feet.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Gatineau: 1 killed

Date & Time: Jun 14, 2004 at 1340 LT
Type of aircraft:
Registration:
C-GJST
Flight Type:
Survivors:
No
Schedule:
Gatineau - Gatineau
MSN:
1368
YOM:
1959
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1709
Captain / Total hours on type:
700.00
Circumstances:
The pilot and sole occupant of the DHC-2 seaplane, registration C-GJST, serial number 1368, was on his first flight of the season on the Ottawa River at Gatineau, Quebec. This training flight, conducted according to visual flight rules, was to consist of about 12 touch-and-go landings. The aircraft took off at approximately 1300 eastern daylight time, and made several upwind touch-and-go landings in a westerly direction. At approximately 1340 eastern daylight time, the aircraft was seen about 50 feet above the surface of the water proceeding downwind in an easterly
direction, in a nose-down attitude of over 20 degrees. The right float then struck the water and the aircraft tumbled several times, breaking up on impact. Despite the waves and gusting wind on the river, some riverside residents who witnessed the accident attempted a rescue, but the aircraft sank before they could reach it. Even though the pilot was wearing a seat-belt, he sustained head injuries at impact and drowned.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The aircraft struck the water for undetermined reasons.
Findings as to Risk:
1. The certificate of airworthiness was not in effect at the time of the accident because of the airworthiness directives that had not been completed.
2. The distress signal emitted by the fixed, automatic emergency locator transmitter (ELT) was not received because of the reduced range of the signal once the ELT was submerged, which could have increased the response time of search and rescue units if there had been no witnesses to the accident.
3. The pilot had not made a training flight with an instructor for more than 19 months, which could have resulted in a degradation of his skills and decision-making process.
Final Report:

Crash of a Cessna 560 Citation Encore at Miramar NAS: 4 killed

Date & Time: Mar 10, 2004 at 2042 LT
Type of aircraft:
Operator:
Registration:
165938
Flight Type:
Survivors:
No
Schedule:
Grand Junction - Miramar
MSN:
560-0567
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was returning to Miramar NAS following a routine training mission in Grand Junction. On final approach to Miramar NAS by night, the aircraft crashed near the interstate 15, about 2,400 metres short of runway 24R. The aircraft was destroyed and all four occupants were killed. A weather observation taken from the base at 2045LT reported five-mile visibility with light fog or haze, and a cloud ceiling at 800 feet.
Crew:
Lt Col T. Nicholson,
Lt Col Robert Zeisler.
Passengers:
Sgt Francisco Cortez,
Cpl Jeremy Lindroth.

Crash of a Canadair CL-415 off Les Salles-sur-Verdon: 2 killed

Date & Time: Mar 8, 2004 at 1100 LT
Type of aircraft:
Operator:
Registration:
F-ZBEZ
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Marseille
MSN:
2018
YOM:
1996
Flight number:
Pélican 41
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
One instructor and two pilots under supervision departed Marseille-Marignane Airport on a training flight. Several scooping manoeuvres were completed on the Sainte-Croix Lake located about 85 km northeast of Marseille. While completing a new scooping procedure, the aircraft approached in a high nose attitude and disintegrated upon landing. The main wreckage sank to a depth of 31 metres off Les Salles-sur-Verdon. One pilot was found alive but seriously injured due to hypothermia (the water temperature was 6° C) while both other occupants, Jean Beauvais and Jean-Pierre Laty, were killed.

Crash of a Beechcraft C90 King Air near Madrid-Getafe AFB: 2 killed

Date & Time: Feb 18, 2004 at 1130 LT
Type of aircraft:
Operator:
Registration:
E.22-03
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Madrid-Getafe - Madrid-Getafe
MSN:
LJ-624
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a local training flight at Madrid-Getafe AFB when the aircraft crashed in unknown circumstances near Parla, about 8 km south of the airbase. The aircraft was destroyed and both pilots were killed.

Crash of a Cessna 208 Caravan I off Green Island

Date & Time: Feb 8, 2004 at 1610 LT
Type of aircraft:
Operator:
Registration:
VH-CYC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cairns - Cairns
MSN:
208-0108
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5333
Captain / Total hours on type:
211.00
Circumstances:
The aircraft, with two pilots on board, was being operated for pilot type endorsement training. Air Traffic Control (ATC) had cleared the pilots to conduct upper level air work between 4,000 and 5,000 ft above mean sea level (AMSL) within a 5 NM radius of Green Island, Queensland. Following the upper level air work, the crew requested, and were granted a clearance for, a simulated engine failure and descent to 2,000 ft. The pilot in command (PIC) reported that while completing the simulated engine failure training, he had retarded the power lever to the FLIGHT IDLE stop and the fuel condition lever to the LOW IDLE range, setting a value of 55% engine gas generator speed (Ng). The pilot under training then set the glide attitude at the best glide speed (for the operating weight) of about 79 knots indicated airspeed (KIAS). The PIC then instructed the pilot under training to place the propeller into the feathered position, and maintain best glide speed. The PIC reported that he instructed the pilot under training to advance the emergency power lever (EPL) to simulate manual introduction of fuel to the engine. According to the PIC, he then noticed that there was no engine torque increase, with the engine inter-turbine temperature (ITT or T5) and Ng rapidly decreasing, and a strong smell of fuel in the cockpit. While the pilot under training flew the aircraft, the PIC placed the ignition switch to the ON position and also selected START on the engine starter switch. He then reportedly placed the EPL to the CLOSED position, the propeller to the UNFEATHERED position and the fuel condition lever to the IDLE CUTOFF position to clear the excess fuel from the engine. The PIC reported that they then increased the aircraft airspeed to 120 KIAS, at which point he reintroduced fuel into the engine by advancing the fuel condition lever. He reported that following these actions, the strong fuel smell persisted. As the aircraft approached 1,500 ft, the PIC broadcast a MAYDAY, informing ATC that they had a 'flameout' of the engine and that they were going to complete a forced landing water ditching near Green Island. While the pilot under training flew the aircraft, the PIC placed the propeller into the feathered position, closed the fuel condition lever to the IDLE CUTOFF position and turned off the starter and ignition switches. They then completed a successful landing in a depth of about 2 m of water near Green Island. The pilots evacuated the aircraft without injury. The aircraft, which sustained minor damage during the ditching, but subsequent substantial damage due to salt water immersion, was recovered to the mainland. Following examination of all connections and control linkages, the engine was removed for examination under the supervision of the Australian Transport Safety Bureau (ATSB) at the engine manufacturer's overhaul facility. The engine trend monitoring (ETM) data logger was also removed from the aircraft for examination.
Probable cause:
The following factors were identified:
1. The pilots of CYC were conducting in-flight familiarization training using the emergency power lever. That procedure was not contained in the aircraft manufacturer's pilot operating handbook.
2. The engine manufacturer's documentation contained information on the use of the emergency power lever, which did not preclude the use of the emergency power lever for in-flight familiarization training.
3. The engine sustained a flameout at an altitude above mean sea level from which reignition of the engine was not successfully completed.
4. Erosion of the first-stage compressor blades would have reduced the aerodynamic efficiency of the compressor blades.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) off Byron Bay: 2 killed

Date & Time: Jan 27, 2004 at 1335 LT
Operator:
Registration:
VH-WRF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Coolangatta - Coolangatta
MSN:
61-0497-128
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7127
Captain / Total hours on type:
308.00
Copilot / Total flying hours:
283
Copilot / Total hours on type:
3
Circumstances:
The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.
Probable cause:
Without the aircraft wreckage or more detailed information regarding the behaviour of the aircraft in the final stages of the flight, there was insufficient information available to allow any conclusion to be drawn about the development of the accident. Many possible explanations exist. The fact that no radio transmission was received from the aircraft around the time radar contact was lost could indicate that the aircraft was involved in a sudden or unexpected event at that time that prevented the crew from operating the radio. The speed regime of the aircraft during the last recorded data points indicated that airframe failure due to aerodynamic overload was unlikely. The nature of the items from the aircraft that were recovered from the ocean surface indicated that the aircraft cabin had been ruptured during the accident sequence.
Final Report: