Crash of a Cessna 421B Golden Eagle II near Telluride: 1 killed

Date & Time: Jan 2, 2000 at 0950 LT
Operator:
Registration:
N421CF
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Montrose - Las Cruces
MSN:
421B-0513
YOM:
1973
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3700
Captain / Total hours on type:
200.00
Aircraft flight hours:
3154
Circumstances:
The non-instrument rated private pilot departed Montrose, Colorado, southbound in a Cessna 421B. According to radar data, the airplane climbed from 14,300 to 16,600 feet msl at a rate of 1,792 fpm. The data shows that 19 seconds later, the airplane lost 4,000 feet of altitude, or descended at a rate of 12,631 fpm. The airplane then climbed back to 13,300 feet msl at a rate of 1,448 fpm, and then disappeared from radar. The airplane crashed in snow covered mountainous terrain. Snowmobilers, who were in the vicinity of the impact site at the time of the accident, said that snow showers made visibility less than 1/2 sm. A pilot departing Telluride Regional Airport (located 33 nm at 045 degrees from the crash site), on a heading of 300 degrees, at approximately 1015 said that it was clear right over Telluride. He said that as he climbed out, he got into weather at 12,000 feet msl, and didn't break out until 22,000 feet msl. He also said that he experienced no icing or turbulence during his climb out.
Probable cause:
The non-instrument rated pilot's intentional flight into IMC, and his subsequent spatial disorientation that resulted in an inadvertent stall. A factor was the snow showers weather condition.
Final Report:

Crash of a Yakovlev Yak-42D in Valencia: 22 killed

Date & Time: Dec 25, 1999 at 2015 LT
Type of aircraft:
Operator:
Registration:
CU-T1285
Survivors:
No
Site:
Schedule:
Havana - Valencia
MSN:
49 14 068
YOM:
1989
Flight number:
CU310
Country:
Crew on board:
12
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
22
Circumstances:
The three engine aircraft departed Havana Airport on a special flight to Valencia-Arturo Michelena Airport with 12 passengers and 10 crew members on board. They were on their way to Valencia to pick up Cuban rescuers who were recently dispatched in Venezuela to help local authorities following heavy floods that killed more than 10,000 people. Following a holding circuit of about 40 minutes, the crew was cleared to descend from 8,000 feet to 4,000 feet when, on final, the aircraft struck the slope of Mt San Luis located 12 km short of runway. The aircraft disintegrated on impact and all 22 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew started the descent prematurely and continued below the minimum safe altitude until the aircraft impacted terrain. At the time of the accident, the visibility was reduced due to the night.

Crash of a De Havilland DHC-6 Twin Otter 300 in Simara: 10 killed

Date & Time: Dec 25, 1999 at 1502 LT
Operator:
Registration:
9N-AFL
Flight Phase:
Survivors:
No
Site:
Schedule:
Simara - Kathmandu
MSN:
796
YOM:
1982
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The twin engine aircraft departed Simara Airport at 1457LT on a schedule flight to Kathmandu with 10 people on board. Three minutes after takeoff, while climbing in marginal weather conditions, the aircraft struck the slope of Mt Burja Lek located few km from the airport. The aircraft disintegrated on impact and all 10 occupants were killed. At the time of the accident, the visibility was estimated to be 5 km with low ceiling.
Probable cause:
Controlled flight into terrain after the crew failed to follow the correct route after takeoff and continued at an insufficient altitude until the aircraft collided with terrain.

Crash of a Cessna 208B Grand Caravan near Adjuntas

Date & Time: Dec 23, 1999 at 1600 LT
Type of aircraft:
Registration:
N1315A
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Ponce - Aguadilla
MSN:
208B-0655
YOM:
1998
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1985
Captain / Total hours on type:
550.00
Aircraft flight hours:
1427
Circumstances:
While en route to the first schedule stop, the pilot heard a radio transmission that weather conditions in the vicinity of his next destination were 'bad.' Upon arriving, the pilot attempted to telephone Flight Service for a weather briefing and to file a flight plan. After efforts to contact Flight Service failed, the pilot elected to takeoff without a filing a flight plan. A few minutes into the flight, the pilot decided to return to the departure airport after the flight encountered deteriorating weather conditions that included heavy turbulence, and low ceilings. The airplane collided with trees as the pilot maneuvered the airplane. The post-accident examination of the airplane failed to disclose a mechanical malfunction or a component failure. The pilot did not report a mechanical problem with the airplane. A review of the en route flight charts disclosed that the terrain elevation at the departure point was approximately 24 feet. The terrain elevation at the approximate location of the accident site was 2,500 feet.
Probable cause:
The pilot continued flight into adverse weather conditions that included low ceiling and turbulence. Factors to the accident were trees.
Final Report:

Crash of an IAI-1124A Westwind II near Gouldsboro: 3 killed

Date & Time: Dec 12, 1999 at 1635 LT
Type of aircraft:
Registration:
N50PL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Seattle - Teterboro
MSN:
338
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10250
Captain / Total hours on type:
1500.00
Aircraft flight hours:
5035
Circumstances:
After a 5-hour flight, the Westwind jet began its descent to the airport. Air traffic control instructed the flight crew to cross a VOR at 18,000 feet. The flight crew was then instructed to cross an intersection at 6,000 feet. The flight crew needed to descend the airplane 12,000 feet, in 36 nautical miles, to make the crossing restriction. The flight crew acknowledged the clearance, and no further transmissions were received from the airplane. The airplane struck treetops and impacted the ground in a wooded area. The accident flight was the airplane's first flight after maintenance. Work that was accomplished during the maintenance included disassembly and reassembly of the horizontal stabilizer trim actuator. Examination of the actuator at the accident site revealed that components of the actuator were separated and that they displayed no damage where they would have been attached. Examination of the actuator by the Safety Board revealed that the actuator had not been properly assembled in the airplane. A similar actuator was improperly assembled and installed in a static airplane for a ground test. When the actuator was run, the jackscrews of the actuator were observed backing out of the rod end caps within the first few actuations of the pitch trim toward the nose-down position. As the pitch trim continued to be actuated toward the nose-down position, the jackscrews became disconnected from the rod end caps, and the horizontal stabilizer became disconnected from the actuator. The passenger was Peter Lahaye, founder and owner of the Lahaye Laboratories and the aircraft.
Probable cause:
The improper assembly of the horizontal stabilizer trim actuator unit by maintenance personnel.
Final Report:

Crash of a BAe ATP on São Jorge Island: 35 killed

Date & Time: Dec 10, 1999 at 1018 LT
Type of aircraft:
Operator:
Registration:
CS-TGM
Flight Phase:
Survivors:
No
Site:
Schedule:
Ponta Delgada - Horta
MSN:
2030
YOM:
1990
Flight number:
SP530
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
31
Pax fatalities:
Other fatalities:
Total fatalities:
35
Captain / Total flying hours:
19721
Captain / Total hours on type:
2652.00
Copilot / Total flying hours:
5827
Copilot / Total hours on type:
514
Aircraft flight hours:
11305
Aircraft flight cycles:
23584
Circumstances:
The aircraft departed Ponta Delgada Airport at 0930LT on a schedule flight to Horta, carrying 31 passengers and a crew of four. The weather en route was affected by a frontal system with scattered cumulonimbus, heavy showers, turbulence and strong winds from the southwest. The crew decided to alter their flight plan, opting for a route that included approach descent over the channel between Pico and São Jorge islands to intercept the 250 degree VOR/VFL Horta radial. Horta tower initially cleared the flight to FL100. The crew then requested and were cleared to descent to 5,000 feet with the instruction of maintaining visual contact with Pico Island. During the descent heavy rain and turbulence were encountered. Seven minutes after initiating the descent, while in IMC conditions, the airplane impacted the northern hillside of Pico da Esperança (1067 metres high) located on São Jorge Island. It was later reported that the GPWS alarm sounded 17 seconds before impact. The aircraft disintegrated on impact and all 35 occupants were killed.
Probable cause:
Controlled flight into terrain after the crew failed to maintain the proper altitude. The following factors were identified:
- Inaccurate navigation configuration on part of the crew,
- The crew failed to properly use the weather radar,
- The crew failed to pay sufficient attention to the radio altimeter settings,
- The aircraft was not equipped with a modern and autonomous navigation system which may allow the crew to know their position with more precision,
- Lack of visibility due to poor weather conditions.
Final Report:

Crash of a Piper PA-31-310 Navajo B in Sundsvall: 8 killed

Date & Time: Dec 9, 1999 at 1204 LT
Type of aircraft:
Operator:
Registration:
SE-GDN
Flight Phase:
Survivors:
No
Site:
Schedule:
Sundsvall – Göteborg
MSN:
31-7300947
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
729
Captain / Total hours on type:
98.00
Aircraft flight hours:
7266
Circumstances:
Events prior to the flight:
On Wednesday the 8th of December 1999 at 08:32 hrs. the pilot took off with the aircraft from Gothenburg/Landvetter airport for an IFR flight to Sundsvall/Härnösand airport via Östersund/Frösön F4 airport. Present onboard were seven passengers, all employed by a company in Gothenburg. The flight proceeded via the reporting point of MEGEN (6001N 1424E) and they landed at 10:45 hrs. in Östersund. After a short groundstop to deplane one of the passengers, they took off 13 minutes later to continue the flight to Sundsvall. It was beautiful weather in Sundsvall. The wind was 320 degrees at 12 knots and the temperature –12°C. The pilot performed a visual approach to runway 34 and landed at 11:33 hrs. After the landing he parked the airplane for the night on spot 25 on the southern tarmac, designated “Apron S” (ref. 1.10). According to what he stated later that evening, he placed covers on the aircraft wings and stabilizer and connected electricity for heating in the cabin and engines before he, along with his passengers, departed for the city of Sundsvall. In Sundsvall they had lunch and had a business meeting with a subcontractor, which was concluded at approximately 16:00 hrs, at which time they were driven to the hotel. Around 19:00 hrs. the party dined at a restaurant together with a few of the employees from the subcontractor. The consumption of alcoholic beverages was sparse and none of the persons that SHK has talked with observed the pilot consume anything other than non-alcoholic beverage. Dinner concluded around 23:30, after which the party returned to the hotel. The following morning it was snowing. The group was picked-up around 08:00 hrs. and initially made a short visit at a factory. Thereafter they were driven to the subcontractor’s office where they had a short coffee break and then continued their business meeting. During the trip to the office the pilot called the airport and ordered weather information that was faxed to the office. On questions to the pilot concerning flying in the bad weather, his response was that it was no problem. If he had felt doubtful in that respect, he would cancel the flight. However, due to the weather situation the pilot decided not to perform the return flight to Gothenburg via Östersund. The passenger that was there had to get to Sundsvall with other means of transport and join the group at the airport.
Preparations before the flight:
The business meeting was concluded at time 10:30 hrs. A taxi had been booked for that time. Due to the taxi being somewhat late the group arrived at the airport around 11:15. The passengers remained in the flight planning room in the terminal building while the pilot ordered fueling and went out to prepare the aircraft for the flight. He had filed a flight plan by telephone earlier in the day. Departure was planned for 11:30 hrs. and the flight time was estimated to be 2 hours and 20 minutes. When the fueling order came, the fueling personnel were busy refueling another aircraft with type JET A-1 fuel. The tanker truck with AVGAS 100LL fuel had not been in use earlier that day. Prior to re-fueling with this truck it was drained and prepared for refueling. When the fueling personnel arrived at the aircraft the pilot was already in the aircraft warming-up the engines. He cut the engines and requested to have “full wings”. A total of 396 liters of fuel were uploaded in the aircraft's four fuel tanks. The fueling personnel noted that the aircraft wings were free from ice and snow. The pilot contacted the air traffic controller in the tower at 11:41.38 and requested clearance to taxi, which was granted, to the flight planning office next to Apron M, in order to pick up his passengers. At 11:49.24 hrs. the pilot again contacted the tower controller and requested clearance to startup the engines and at the same time reported that he had received the weather information. Four minutes later he requested taxi instructions and was cleared to taxi to holding position “Charlie” on the taxiway (ref. 1.10). After further instructions from the air traffic controller the pilot taxied to the specified position and held there for a departing SAS (Scandinavian Airlines) aircraft. The air traffic controller thought that the aircraft appeared to be free from snow when it was parked on Apron M, but that a thin layer of snow had accumulated when it taxied out for take off. The Commander of the departing SAS aircraft has recounted that both the approach and the departure from Sundsvall that day were difficult due to poor visibility, heavy snowfall and gusty winds. During taxi on the runway snowdrifts had occurred that created strands of blowing snow. He estimated the visibility to be 600-700 meters. During take off he was “fully occupied maneuvering the 58 ton heavy MD 80 in the wind gusts.
The Flight:
When the SAS aircraft had departed the pilot received clearance to taxi out to the take off position on runway 16. At the same time he received air traffic control clearance to Gothenburg/Landvetter via reporting point MEGEN at flight level 120 (approximately 3 660 meters), and the transponder code of 6377. He was also requested to report when the aircraft had reached the take off position, as the air traffic controller could not see the aircraft in the snowfall. At 12:00.18 hrs. the pilot reported that he had lined up into take off position. The controller then reported that the wind was 120 degrees at 17 knots, that the pilot was to make a right turn after take off and that he was cleared for takeoff. When the aircraft was airborne the pilot was to contact Sundsvall Control on frequency 135.02 MHz. The pilot read back these instructions and thereafter took off. The tower controller visually observed the aircraft a short moment during the take off as it passed abeam the control tower, then it disappeared again out of his sight due to the snowfall. A witness, who is a former pilot himself and was on the northern part of Alnön (an island), about 5 km south of the airport, heard the aircraft take off. After take off he heard that the engine rpm decreased somewhat and thereafter heard the characteristic sound that can arise on a multi-engine aircraft when the engines are not totally synchronized with the adjustment of the throttles and propeller levers. The sound of the engines became normal after a while. When the sound faded out is was perceived as normal for a twin engine aircraft. Witnesses who were situated along the flight path of the aircraft heard it and a few observed the aircraft during a short moment through the heavy snowfall. Several felt that the aircraft was flying low but that the sound of the engines was normal. One witness observed that the landing gear was retracted. In the vicinity of Kvickberget northwest of the airport a few witnesses heard that the engine rpm increased sharply. After that it was silent. Approximately two minutes after take off the tower controller observed that the echo from aircraft SE-GDN on his radarscope was not following the route cleared but had turned to the north. He made an inquiry with the air traffic controller at Sundsvall Control and received word that the same had not yet been contacted by the aircraft. The tower controller then contacted the aircraft on tower frequency and asked the pilot if he was experiencing problems. The pilot responded that he did have problems and in response to the controller’s inquiry about his intentions, the pilot answered “Climbing” twice and thereafter “-I have a problem with the eeee … uuumm .. with the compass at, at this moment, so could you, could you give me a … di, direction at this moment.” The tower controller then answered “Ja, you are climbing towards the north-west now, turn left about 90 degrees and climb as soon as possible, you meeting terrain.” Subsequently the tower controller was unable to attain any further radio contact with the aircraft.
Rescue operations:
At time 12:04.27 radio signals from an emergency locator transmitter were perceived in the area and the air traffic controller triggered the alarm button to the SOS center and alerted the air rescue services at ARCC. It was agreed upon to apply the yellow checklist, which meant assumed crash with unknown crash site. The airport was closed. The SOS center alerted according to the alert plan for an assumed crash. A suitable breakpoint (where the ground rescue party has to depart from the surface road structure) was chosen in connection with the area where the aircraft disappeared. ARCC alerted a search and rescue helicopter that was stationed at Sundsvall/Härnösand airport. The crew of the search and rescue helicopter received the alarm at 12:10 hrs. and was airborne with the helicopter at 12:24. Six minutes later the aircraft was located in the forest on the southern slope of a mountain known as Kvickberget. The helicopter lowered rescue personnel on the winch who ascertained that none of the persons on board had survived. They were only able however to find five persons and searched through an area around the downed aircraft without results. Police, ambulances and fire vehicles reached the breakpoint between 12:21 and 12:27 hrs. The SOS center received the exact position of the accident site at 12:35 hrs. and the breakpoint was moved to a road intersection about 4 km from there. The forest road towards the accident site was unplowed and two tracked vehicles had to begin the trip while snow plows cleared the forest road so that ambulances and fire vehicles could make their way. The last portion from the forest road up to the aircraft was approximately 300 meters long and consisted of a ravine and difficult terrain. Medical and fire personnel had to make there way on foot this last portion and reached the accident site at 13:30 hrs. They verified that none of the persons onboard had survived and found that there was an imminent risk of fire because of the large quantity of aviation gas that had been spread at the site. Hand-held fire extinguishers and police search and rescue dogs were requisitioned to the site. At 14:36 hrs. it was reported to SOS that additionally three people had been found in the aircraft. At 19:40 hrs. the last of the victims were transported from the accident site. A crisis group was established at Sundsvall/Härnösand airport. About 40 persons participated in the rescue operations at the site, which was concluded at 23:39 hrs. Despite the difficult terrain, which limited the availability of equipment, the general consensus was that the search and rescue action had worked well. The accident occurred at location: 6233N 1719E; approximately 200 m above sea level. All eight occupants were killed.
Probable cause:
The accident was caused by the pilot losing control of the aircraft during flight in IMC.
The following contributory factors were identified:
- The weather situation was difficult,
- The pilot’s time to prepare for the flight was insufficient,
- The navigation system was in all probability misaligned,
- The pilot mistrusted the flight instruments,
- The aircraft was overloaded and tail-heavy,
- The pilot probably felt pressured into carrying out the flight,
- The pilot’s medical condition can have reduced his ability.
Final Report:

Crash of an Antonov AN-14A near Khvishchanka: 3 killed

Date & Time: Dec 9, 1999
Type of aircraft:
Operator:
Registration:
FLARF-02373
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Novopokrovka - Arsenyev
MSN:
0 033 10
YOM:
1970
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Made airworthy again in 1999 (was the last flying An-14) and used for short communications flights. Destroyed on a flight from Novopokrovka to Arsenyev when entered a snow flurry while flying along the valley of the river Bystraya. The crew decided to divert to the nearest airfield but while the aircraft was turning, the wing hit a tree on the slope of Mt Zolotaya (945 metres high) located 14 km northwest of Khvishchanka and the aircraft crashed. A pilot and two passengers (aviation mechanics) were killed and all 3 survivors injured. The wreckage was founded a day later.

Crash of a Let L-410UVP-E near Kasibu: 17 killed

Date & Time: Dec 7, 1999 at 0930 LT
Type of aircraft:
Operator:
Registration:
RP-C3883
Flight Phase:
Survivors:
No
Site:
Schedule:
Manila - Cauayan
MSN:
89 22 28
YOM:
1989
Flight number:
RIT100
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
10000
Circumstances:
The twin engine aircraft departed Manila-Ninoy Aquino Airport at 0834LT and was supposed to arrive at Cauayan Airport at 0940LT. At 0919LT, the crew reported his position 96 km from the destination. As he encountered favorable winds, the captain informed ATC about an ETA three minutes earlier at 0937LT. At 0930LT, while flying in clouds, the aircraft struck the slope of a mountain located near Kasibu, about 77 km southwest of Cauayan Airport. The aircraft was destroyed upon impact and all 17 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of an ATR42-312 near Kosovska Mitrovica: 24 killed

Date & Time: Nov 12, 1999 at 1115 LT
Type of aircraft:
Operator:
Registration:
F-OHFV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rome - Pristina
MSN:
12
YOM:
1986
Flight number:
KSV3275
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
24
Captain / Total flying hours:
18000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
1500
Aircraft flight hours:
24930
Aircraft flight cycles:
32810
Circumstances:
Arriving from Rome, the aircraft chartered by the World Food Program was going to land at Pristina. The meteorological conditions at the aerodrome corresponded to visibility of 4,000 metres with a layer of compact clouds at 3,000 feet. In radar and radio contact with the military air traffic control organisation for an ILS approach, the aircraft, which was outbound to the north at an altitude of 4,600 feet, entered a sector where the minimum safety altitude is 6,900 feet and struck a mountain whose peak is at 4,650 while turning to return towards the airport. The wreckage was found about 15 metres below the summit, some 18 km northeast of Kosovska Mitrovica and 42 km north of Pristina Airport. All 24 occupants were killed.
Probable cause:
The collision of Flight KSV 3275 with high ground was due to:
- Teamwork which lacked procedural discipline and vigilance during maneuvers in a mountainous region with poor visibility,
- The aircraft being kept on its track and then forgotten by a military controller unused to the mountainous environment of the aerodrome and to preventing the risk of collisions with high ground, within the framework of the radar service he was providing,
- The operator's critical situation as a new company highly dependant on the lease contract, favoring a failure to respect procedures,
- The opening of the aerodrome to civil traffic without an advance evaluation of the operating conditions or of the conditions for distribution of aeronautical information.
The following factors contributed to the accident :
- Crew fatigue, favoring a lowering of vigilance,
- Undertaking the flight with an unserviceable or disconnected GPWS.
Final Report: