Crash of a Piper PA-31-350 Navajo Chieftain in San Jose: 2 killed

Date & Time: Dec 23, 1995 at 0019 LT
Operator:
Registration:
N27954
Flight Type:
Survivors:
No
Site:
Schedule:
Oakland - San Jose
MSN:
31-7952062
YOM:
1979
Flight number:
AMF041
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4659
Captain / Total hours on type:
914.00
Aircraft flight hours:
9840
Aircraft flight cycles:
10966
Circumstances:
The aircraft impacted mountainous terrain in controlled flight during hours of darkness and marginal VFR conditions. The flight was being vectored for an instrument approach during the pilot's 14 CFR Part 135 instrument competency check flight. The flight was instructed by approach control to maintain VFR conditions, and was assigned a heading and altitude to fly which caused the aircraft to fly into another airspace sector below the minimum vectoring altitude (MVA). FAA Order 7110.65, Section 5-6-1, requires that if a VFR aircraft is assigned both a heading and altitude simultaneously, the altitude must be at or above the MVA. The controller did not issue a safety alert, and in an interview, said he was not concerned when the flight approached an area of higher minimum vectoring altitudes (MVA's) because the flight was VFR and 'pilots fly VFR below the MVA every day.' At the time of the accident, the controller was working six arrival sectors and experienced a surge of arriving aircraft. The approach control facility supervisor was monitoring the controller and did not detect and correct the vector below the MVA.
Probable cause:
The failure of the air traffic controller to comply with instructions contained in the Air Traffic Control Handbook, FAA Order 7110.65, which resulted in the flight being vectored at an altitude below the minimum vectoring altitude (MVA) and failure to issue a safety advisory. In addition, the controller's supervisor monitoring the controller's actions failed to detect and correct the vector below the MVA. A factor in the accident was the flightcrew's failure to maintain situational awareness of nearby terrain and failure to challenge the controller's instructions.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Horn Island: 1 killed

Date & Time: Dec 12, 1995 at 0918 LT
Operator:
Registration:
VH-UJP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Horn Island - Horn Island
MSN:
500-3074
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11740
Captain / Total hours on type:
119.00
Circumstances:
At approximately 0910 EST, the aircraft took off from runway 32 at Horn Island and commenced a normal climb. Shortly after, it adopted a nose-high attitude and commenced a wingover type manoeuvre to the right. Witnesses described the aircraft as being in a nose-low attitude, and at a height of approximately 600 ft to 700 ft above ground level after the completion of this manoeuvre. It then abruptly adopted a level attitude and rapidly entered a spin to the left. Witnesses on the ground reported that at approximately the same time as the aircraft entered the spin, engine power became asymmetric, with the right engine continuing to deliver considerable power. The aircraft continued to descend in a fully developed flat spin, with no observed signs of an attempt to recover. The impact was heard shortly after the aircraft descended behind vegetation to the north-west of the aerodrome. The accident was reported to Flight Service by radio at 0918. The wreckage was located on a beach approximately 2 km to the north-west of the aerodrome. The aircraft was destroyed by impact forces and the pilot sustained fatal injuries.
Probable cause:
The following findings were reported:
1. The pilot held a valid pilot licence and medical certificate.
2. The pilot was endorsed on the aircraft type.
3. The aircraft entered a flat spin to the left with no reported signs of an attempt to recover.
4. The aircraft struck the ground whilst established in a flat left spin.
5. The right engine was producing considerable power prior to impact.
6. Indications were that the left engine was producing little or no power. Its propeller was in the feathered position prior to impact.
7. No evidence was found to indicate a malfunction or pre-existing defect with the aircraft or its systems which may have affected normal operation during this flight.
8. No evidence was found to indicate pilot incapacitation as the result of a medical condition or the presence of alcohol or drugs.
9. The pilot's behaviour on the morning of the accident was not consistent with what was generally accepted to be a thorough and professional attitude to aviation.
Final Report:

Crash of a Beechcraft D18S in Fort Collins

Date & Time: Nov 30, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
N8603A
Flight Type:
Survivors:
Yes
Schedule:
Fort Collins - Fort Collins
MSN:
A-557
YOM:
1951
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
800.00
Circumstances:
The pilot-owner/operator, who was seated in the right seat, said the left seat pilot made the approach to runway 15. The wind was reported as being from the southwest at 20 knots with no reference to gusts. He said the pilot aligned the airplane 40 feet left of runway centerline and failed to flare. The airplane contacted the runway, bounced back into the air with the right wing high, and began drifting to the left. The right seat pilot took control, first trying to lower the wing then attempting to abort the landing. The airplane struck the ground and cartwheeled. The left seat pilot said he was 'receiving training' from the pilot-owner and was 'not at the controls' at the time of the accident.
Probable cause:
The second pilot's failure to compensate for wind conditions and his improper recovery from a bounced landing, and the pilot-in-command's inadequate supervision of the flight. Factors were the second pilot's lack of landing experience in the airplane make/model, and the gusty crosswind conditions.
Final Report:

Crash of an Antonov AN-24B in Shymkent

Date & Time: Nov 1, 1995
Type of aircraft:
Operator:
Registration:
UN-47710
Flight Type:
Survivors:
Yes
Schedule:
Shymkent - Shymkent
MSN:
6 99 004 05
YOM:
1966
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Shymkent Airport. On approach, at an altitude of about 300 metres, the instructor shut down one engine to simulate a failure. The pilot-in-command requested full power on the remaining engine but the flight engineer misinterpreted the instruction and shut down the second engine. The aircraft lost speed and height and struck the ground with a positive acceleration of 2,6 g before coming to rest in a field 1,100 metres short of runway threshold. All four occupants were injured and the aircraft was damaged beyond repair.
Probable cause:
Loss of control on final approach due to lack of crew coordination during an engine failure simulation.

Crash of a Morane-Saulnier M.S.760B Paris II in Uzech: 4 killed

Date & Time: Oct 11, 1995
Operator:
Registration:
117
Flight Phase:
Flight Type:
Survivors:
No
MSN:
117
YOM:
1962
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
While in a training flight, the aircraft went out of control and crashed in a field located in Uzech, about 15 km north of Cahors, Lot. The aircraft was destroyed and all four occupants were killed.
Crew:
Cpt Jean-Marie Bachelot,
Cpt Henri-Claude Johary.
Passengers:
Michel Magnier,
Jacqueline Spirkovitch.
Probable cause:
It was reported that an engine failed in flight and caught fire for unknown reasons.

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a De Havilland DHC-4A Caribou off Labuan: 3 killed

Date & Time: Jul 31, 1995 at 1244 LT
Type of aircraft:
Operator:
Registration:
M21-13
Flight Type:
Survivors:
Yes
Schedule:
Labuan - Labuan
MSN:
281
YOM:
1969
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a local training flight at Labuan Airport. Following several touch-and-go manoeuvres, the crew initiated a new approach when one of the engine failed. The aircraft stalled and crashed in the sea few hundred metres offshore. Three crew members were killed and three others were seriously injured.
Probable cause:
Engine failure on approach for unknown reasons.

Crash of a Fokker F27 Friendship 500RF in Baroda

Date & Time: Jul 1, 1995 at 0840 LT
Type of aircraft:
Operator:
Registration:
VT-EWE
Flight Type:
Survivors:
Yes
Schedule:
Baroda - Baroda
MSN:
10605
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9360
Circumstances:
The aircraft was engaged in a training flight at Baroda airport. It was under the command of an examiner pilot with the trainee pilot on right hand seat. The first touch and go exercise was uneventful. During the second exercise, immediately on touchdown the left main landing gear failed at its shock strut outer cylinder and the inner cylinder with the main wheel assembly attached to it got liberated. The aircraft continued moving forward with the remaining portion of left shock strut contacting the runway followed by the left engine propellers and fuselage bottom and finally came to rest on the runway left side strip. There was no fire and no injury to persons on board the aircraft.
Probable cause:
The accident occurred during aircraft touchdown due to liberation of the sliding piston along with the wheels of the left main landing gear as a result of failure of the locking arrangement on the piston top end. Non-compliance by the operator of the Service Bulletin issued by the Manufacturer and Mandatory Modifications issued by the DGCA regarding piston-adapter and dowel pin lock fitment, is the Contributory Factor in the accident.
Final Report:

Crash of a Grumman G-21E Turbo Goose in DuPage: 2 killed

Date & Time: Jun 13, 1995 at 1955 LT
Type of aircraft:
Registration:
N121H
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
DuPage - DuPage
MSN:
1211
YOM:
1942
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4200
Captain / Total hours on type:
400.00
Circumstances:
This was the first flight of the Grumman G-21 in two years. Also, the pilot had not flown the G-21 for two years. Before taking off, the pilot reported that three takeoffs and landings would be needed for purposes of becoming current. After takeoff, he flew the airplane approximately one hour and made two full stop landings. During the third takeoff, the airplane was described as lifting off in a short distance and going into a nose high attitude below an altitude of 100 feet. The airplane then rolled left, struck the ground in a steep descent, and burned. Witnesses reported that the engines were providing power until impact; the engines and propellers had evidence of rotational damage. The flap actuators were found extended to a position that equated with 30° of flaps (half flaps). Four G-21 pilots were interviewed. According to them, flaps were not normally used for takeoff in this airplane. They reported that the turboprop engines had substantial power for the weight of the airplane, especially when the plane was not loaded, and that the G-21 would tend to become airborne quickly with flaps extended. No pre impact mechanical problem was noted during the investigation.
Probable cause:
The pilot allowed excessive nose-up rotation of the airplane during lift-off, and failed to obtain and/or maintain adequate airspeed, which resulted in an inadvertent stall and collision with the terrain. Factors relating to the accident were: the pilot's lack of recent experience in the make and model of airplane, and the use of flaps during a light weight takeoff.
Final Report:

Crash of a Let L-410UVP in Riga: 2 killed

Date & Time: Jun 7, 1995 at 1300 LT
Type of aircraft:
Operator:
Registration:
146
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Riga - Riga
MSN:
83 11 35
YOM:
1983
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 Riga-Lielvārdes AFB. While passing over runway 36 at a height of 150-200 metres, the pilot-in-command elected to make a barrel when control was lost. The aircraft crashed on runway and was destroyed, killing both occupants.
Probable cause:
Loss of control after the crew attempted hazardous manoeuvres.