Crash of a De Havilland DHC-6 Twin Otter 300 near Ononge: 2 killed

Date & Time: Jul 29, 2004 at 1030 LT
Operator:
Registration:
P2-MBA
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Port Moresby - Ononge
MSN:
353
YOM:
1973
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While descending to Ononge, the crew encountered poor weather conditions and decided to divert to the Yongai Airfield located about 27 km northeast of Ononge. Few minutes later, while cruising at an altitude of 2,286 metres in clouds, the twin engine aircraft struck the slope of a mountain. Rescuers arrived on scene a day later. The loadmaster was seriously injured while both pilots were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Piper PA-31T Cheyenne II near Benalla: 6 killed

Date & Time: Jul 28, 2004 at 1048 LT
Type of aircraft:
Registration:
VH-TNP
Survivors:
No
Site:
Schedule:
Bankstown – Benalla
MSN:
31-7920026
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
14017
Captain / Total hours on type:
3100.00
Aircraft flight hours:
5496
Circumstances:
At 0906 Eastern Standard Time on 28 July 2004, a Piper Aircraft Corporation PA31T Cheyenne aircraft, registered VH-TNP, with one pilot and five passengers, departed Bankstown, New South Wales on a private, instrument flight rules (IFR) flight to Benalla, Victoria. Instrument meteorological conditions at the destination necessitated an instrument approach and the pilot reported commencing a Global Positioning System (GPS) non-precision approach (NPA) to Benalla. When the pilot had not reported landing at Benalla as expected, a search for the aircraft was commenced. Late that afternoon the crew of a search helicopter located the burning wreckage on the eastern slope of a tree covered ridge, approximately 34 km southeast of Benalla. All occupants were fatally injured and the aircraft was destroyed by impact forces and a post-impact fire.
Probable cause:
Significant factors:
1. The pilot was not aware that the aircraft had diverged from the intended track.
2. The route flown did not pass over any ground-based navigation aids.
3. The sector controller did not advise the pilot of the divergence from the cleared track.
4. The sector controller twice cancelled the route adherence monitoring alerts without confirming the pilot’s tracking intentions.
5. Cloud precluded the pilot from detecting, by external visual cues, that the aircraft was not flying the intended track.
6. The pilot commenced the approach at an incorrect location.
7. The aircraft’s radio altimeter did not provide the pilot with an adequate defence to avoid collision with terrain.
8. The aircraft was not fitted with a terrain awareness warning system (TAWS).
Final Report:

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

Date & Time: Jul 10, 2004 at 0858 LT
Operator:
Registration:
N45032
Survivors:
No
Site:
Schedule:
Oxford-Waterbury - Ticonderoga
MSN:
31-8052199
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
32000
Aircraft flight hours:
8159
Circumstances:
The airplane, which was not operating on a flight plan, was proceeding in clear skies to an airport where the passenger was joining his wife. After crossing a lake near the destination, the airplane flew over rising terrain, along a saddleback, until it struck a stand of old-growth trees that jutted above new-growth trees. During the last 48 seconds of radar coverage, the airplane climbed 600 feet with no erratic course deviations. From the accident location, the airport would have been about 5 nautical miles off the airplane's right wing. The pilot had 32,000 hours of flight experience. The passenger was under investigation for fraud, and attempted to obtain life insurance prior to the flight. The passenger had also loaned money to the pilot, and was receiving "flight services" in lieu of cash payment when the pilot failed to pay back the loan. A .380 caliber pistol magazine was found at the accident site with two rounds of ammunition missing; however, no weapon was located at the site, and no weapon of that caliber was known to be associated with either the pilot or the passenger. Premature ventricular complexes (PVCs) were found on electrocardiograms performed in conjunction with the pilot's airman medical certificate applications in 2002 and 2004. The pilot's autopsy report indicated "severe calcific... coronary disease, with 90 percent narrowing of the left anterior descending coronary artery and 75 percent narrowing of the right coronary artery." Cause of death, for both the pilot and passenger, was listed as "undetermined." The autopsy reports also noted that, "due to the inability to perform a complete autopsy...of either of the two aircraft occupants, it cannot be determined whether either the pilot or the passenger were alive or dead at the time of the crash." Post accident inspection of the airplane disclosed no evidence of any preimpact anomalies.
Probable cause:
Reason for occurrence undetermined.
Final Report:

Crash of a Beechcraft 200 Super King Air near Rupert: 2 killed

Date & Time: Jun 13, 2004 at 0830 LT
Operator:
Registration:
N200BE
Flight Type:
Survivors:
No
Site:
Schedule:
Summerville – Lewisburg – Charlotte
MSN:
BB-832
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
10400
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2910
Copilot / Total hours on type:
400
Aircraft flight hours:
9449
Circumstances:
An IFR flight plan and slot reservation were filed for the planned flight over mountainous terrain. The flightcrew intended to reposition to an airport about 30 miles southeast of the departure airport, pick up passengers, and then complete a revenue flight to another airport. The airplane departed VFR, and the flightcrew never activated the flight plan. A debris path was located, consistent with straight and level flight, near the peak of a mountain at 3,475 feet msl. Examination of the wreckage did not reveal any pre-impact mechanical malfunctions. Instrument meteorological conditions prevailed near the accident site, about the time of the accident. Further investigation revealed the aircraft operator was involved in two prior weather related accidents, both of which resulted in fatalities. A third accident went unreported, and the weather at the time of that accident was unknown. Over a period of 14 years, the same FAA principal operations inspector was assigned to the operator during all four accidents; however, no actions were ever initiated as a result of any of the accidents.
Probable cause:
The pilot-in-command's improper decision to continue VFR flight into IMC conditions, which resulted in controlled flight into terrain. Factors were the FAA Principle Operations Inspector's inadequate surveillance of the operator, and a low ceiling.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 3 killed

Date & Time: May 25, 2004 at 1356 LT
Operator:
Registration:
9N-AFD
Flight Type:
Survivors:
No
Site:
Schedule:
Kathmandu - Lukla
MSN:
651
YOM:
1979
Flight number:
YET117
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
While descending to Lukla Airport from the south following a cargo flight from Kathmandu, the crew encountered poor visibility due to clouds when, at an altitude of 11,600 feet, the aircraft struck the slope of a mountain located near the Lamjura Pass, in the Solukhumbu district. The wreckage was found west of the airport and all three crew members were killed.
Probable cause:
Controlled flight into terrain. The following factors were identified:
- Hazardous behaviour and attitudes of the captain such as overconfidence,
- The crew failed to comply with the approach routes, following a direct track,
- The crew failed to follow SOP's,
- The operator's policy for flying in adverse weather were incomplete and not up to date,
- Lack of communication by the operator,
- The operator was unable to perform internal investigations and execute corrective actions when required.

Crash of a Britten-Norman BN-2B-27 Islander near Vallecillos: 2 killed

Date & Time: May 5, 2004 at 1630 LT
Type of aircraft:
Operator:
Registration:
XC-FOE
Flight Phase:
Survivors:
No
Site:
MSN:
2031
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a geophysical survey flight in the region of Vallecillos, Durango. While cruising at an altitude of 2,000 metres, the twin engine aircraft struck the slope of a mountain located in the Sierra del Rosario. Both occupants were killed.

Crash of a Cessna 208B Grand Caravan on Mt Awakapa Tepuy: 7 killed

Date & Time: May 4, 2004 at 1145 LT
Type of aircraft:
Operator:
Registration:
YV-O-CBL-7
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Ciudad Bolívar – Uonquén
MSN:
208B-0926
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The single engine aircraft departed Ciudad Bolívar at 1016LT on a flight to Uonquén, State of Bolívar. En route, around 1100LT, the pilot reported flying at 11,500 feet in poor weather conditions. About 45 minutes later, while cruising at an altitude of 7,000 feet, the aircraft struck the slope of Mt Awakapa Tepuy located in the Chimanta Mountain Range. All seven occupants were killed, among them two church women.
Probable cause:
Controlled flight into terrain.

Crash of a Beechcraft 200 Super King Air in Berkovići: 9 killed

Date & Time: Feb 26, 2004 at 0745 LT
Registration:
Z3-BAB
Flight Type:
Survivors:
No
Site:
Schedule:
Skopje – Mostar
MSN:
BB-652
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The twin engine aircraft departed Skopje on an official flight to Mostar, carrying two pilots and seven passengers, among them Boris Trajkovski, President of the Republic of Macedonia. He was flying to Mostar with members of his government to take part to an economic conference. On approach by night and limited visibility due to marginal weather conditions, the aircraft struck the slope of a mountain located near Berkovići, about 32 km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire and all nine occupants were killed.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the crew initiated the approach prematurely. The following contributing factors were identified:
- Poor approach and landing preparation and planning,
- The crew ignored ATC information about the current meteorological situation at Mostar Airport,
- The crew misinterpreted the Final Approach Fix (FAF) with the Intermediate Approach Fix (IAF), causing the aircraft to start the descent prematurely,
- The crew disengaged the autopilot system during the approach while descending in complex meteorological conditions,
- Poor crew resources management,
- Lack of crew communication,
- The crew failed to comply with SOP's,
- Failure of the pilot-in-command to maintain flight level when the aircraft reached the MDA and failure of the second pilot to give adequate assistance.
Final Report:

Crash of a Cessna 500 Citation I near Cagliari: 6 killed

Date & Time: Feb 24, 2004 at 0549 LT
Type of aircraft:
Operator:
Registration:
OE-FAN
Flight Type:
Survivors:
No
Site:
Schedule:
Rome – Cagliari
MSN:
500-0289
YOM:
1976
Flight number:
CIT124
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5472
Captain / Total hours on type:
2709.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
1600
Aircraft flight hours:
6471
Aircraft flight cycles:
5618
Circumstances:
The aircraft departed Rome-Ciampino Airport on an ambulance flight to Cagliari, carrying three pilots, three doctors and a cooler containing a heart for a patient. The descent to Cagliari-Elmas Airport was initiated by night under VFR mode. After the crew was cleared to descend to 2,500 feet, ATC reported runway 32 in use and asked the crew to report on short final. About two minutes later, at an altitude of 3,333 feet, the aircraft struck the slope of Mt Su Baccu Malu located 32 km northeast of Cagliari Airport. The aircraft was totally destroyed by impact forces and all six occupants were killed.
Probable cause:
The accident, classified as CFIT, was caused by the conduct of the flight at a height significantly below the Area Minimum Altitude, insufficient to maintain the separation from the ground during a night visual approach in the absence of adequate visual reference.
possible contributory factors that have been identified:
- The aircraft instrumentation did not include a GPWS or TAWS, whose installation is not required by law;
- The erroneous descent by visual flight references, confusing the Elmas runway lights, given that the crew had no special familiarity with the area of Cagliari, the onset of a perspective illusions phenomena, with specific reference to the so-called "black hole approach";
- The misunderstanding by crew members, of the Cagliari Approach controllers instruction to transfer to Elmas TWR ('CIT 124 continue not below 2500 feet, further descent with Elmas TWR 120.6 bye') which may have created the impression, despite the crew had confirmed that they are able to separate themselves from the obstacles that the descent down was free of obstructions;
- Failure to use published procedures and available instruments in a descent to a closer airport and in an unfamiliar area , under conditions of total darkness;
- The anticipation of the deviation from the airway perhaps caused [the crew] to try to speed up the arrival at destination, which determined overflying areas of higher elevation;
- Read errors of the elevations listed in the maps consulted, facilitated by the non representation of the ground color;
- The extended period of wakefulness without adequate rest, which may have contributed to a reduction in the performance of the crew.
Final Report:

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

Date & Time: Jan 31, 2004 at 0140 LT
Type of aircraft:
Operator:
Registration:
N5637C
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Honolulu – Hilo
MSN:
414A-0118
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8230
Captain / Total hours on type:
1037.00
Aircraft flight hours:
11899
Circumstances:
The airplane collided with trees and mountainous terrain at the 3,600-foot-level of Mauna Kea Volcano during an en route cruise descent toward the destination airport that was 21 miles east of the accident site. The flight departed Honolulu VFR at 0032 to pickup a patient in Hilo, on the Island of Hawaii. The inter island cruising altitude was 9,500 feet and the flight was obtaining VFR flight advisories. At 0113, just before the flight crossed the northwestern coast of Hawaii, the controller provided the pilot with the current Hilo weather, which was reporting a visibility of 1 3/4 miles in heavy rain and mist with ceiling 1,700 feet broken, 2,300 overcast. Recorded radar data showed that the flight crossed the coast of Hawaii at 0122, descending through 7,400 feet tracking southeast bound toward the northern slopes of Mauna Kea and Hilo beyond. The last recorded position of the aircraft was about 26 miles northwest of the accident site at a mode C reported altitude of 6,400 feet. At 0130, the controller informed the pilot that radar contact was lost and also said that at the airplane's altitude, radar coverage would not be available inbound to Hilo. The controller terminated radar services. A witness who lived in the immediate area of the accident site reported that around 0130 he heard a low flying airplane coming from the north. He alked outside his residence and observed an airplane fly over about 500 feet above ground level (agl) traveling in the direction of the accident site about 3 miles east. The witness said that light rain was falling and he could see a half moon, which he thought provided fair illumination. The area forecast in effect at the time of the flight's departure called for broken to overcast layers from 1,000 to 2,000 feet, with merging layers to 30,000 feet and isolated cumulonimbus clouds with tops to 40,000 feet. It also indicated that the visibility could temporarily go below 3 statute miles. The debris path extended about 500 feet along a magnetic bearing of 100 degrees with debris scattered both on the ground and in tree branches. Investigators found no anomalies with the airplane or engines that would have precluded normal operation. Pilots for the operator typically departed under VFR, even in night conditions or with expectations of encountering adverse weather, to preclude ground holding delays. The pilots would then pick up their instrument flight rules (IFR) clearance en route. The forecast and actual weather conditions at Hilo were below the minimums specified in the company Operations Manual for VFR operations.
Probable cause:
The pilot's disregard for an in-flight weather advisory, his likely encounter with marginal VFR or IMC weather conditions, his decision to continue flight into those conditions, and failure to maintain an adequate terrain clearance altitude resulting in an in-flight collision with trees and mountainous terrain. A contributing factor was the pilot's failure to adhere to the VFR weather minimum procedures in the company's Operations Manual.
Final Report: