Crash of a Cessna 208B Grand Caravan on Mt Silva: 16 killed

Date & Time: Jul 20, 1999 at 0945 LT
Type of aircraft:
Operator:
Registration:
YN-CED
Flight Phase:
Survivors:
No
Site:
Schedule:
Managua – Bluefields
MSN:
208B-0341
YOM:
1993
Flight number:
NIS046
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
The single engine aircraft departed Managua-Augusto C. Sandino Airport in the morning on a flight to Bluefields, carrying two pilots and 14 passengers, most of them members of a development aid organization. While approaching the destination, the crew initiated a VFR descent to Bluefields in marginal weather conditions. At an altitude of 2,000 feet, the aircraft struck the slope of Mt Silva located in the Zelaya Central Mountain Range. The wreckage was found about 50 km west of Bluefields and all 16 occupants were killed, among them a Swiss citizen.
Probable cause:
Controlled flight into terrain after the crew initiated the descent under VFR mode in IMC conditions. The following contributing factors were identified:
- Poor weather conditions with low clouds,
- The crew started the descent prematurely, causing the aircraft to descent at 2,000 feet while the minimum safe altitude was 2,700 feet over the area of the accident.

Crash of a Boeing 727-243F in Kathmandu: 5 killed

Date & Time: Jul 7, 1999 at 1951 LT
Type of aircraft:
Operator:
Registration:
VT-LCI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Katmandu – New Delhi – Sharjah
MSN:
22168
YOM:
1981
Flight number:
LCI8533
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
43000
Aircraft flight cycles:
25000
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport on a cargo flight to Sharjah with an intermediate stop in New Delhi, carrying five crew members and a load of 21 tons of woolen carpets. After takeoff from runway 20, the crew continued to climb but failed to realize his altitude was insufficient. The aircraft struck the slope of Mt Champadevi located 11 km southwest of the airport and disintegrated on impact. All five crew members were killed.
Probable cause:
The accident occurred as the crew after take off did not adhere to the published Standard Instrument Departure (SID) procedure for runway 20 at Kathmandu, Nepal.
The following contributory factors were identified:
- Incomplete departure briefing given by P1 while other cockpit activities were in progress,
- The unexpected airspeed decay to V 2 -3 during initial right climbing turn South of the VOR which occurred while P2 was busy with ATC,
- The improper power and climb profile used by P1 after rolling the aircraft out on a southwest heading following the initial airspeed loss,
- The inadequate intra cockpit crew coordination and communication as the aircraft proceeded to and across the KTM VOR 4 DME arc before recommencing a shallow right turn, and
- The incorrect and slow response to the initial and subsequent GPWS activation prior to the collision with the terrain.

Crash of a Fokker F27 Friendship 600 in Sittwe: 8 killed

Date & Time: Jul 2, 1999 at 1429 LT
Type of aircraft:
Operator:
Registration:
XY-AEO
Flight Type:
Survivors:
No
Site:
Schedule:
Yangon - Sittwe
MSN:
10594
YOM:
1979
Flight number:
UB411
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
The aircraft was completing a cargo flight from Yangon to Sittwe, carrying four passengers, four crew members and a load of construction materials. The descent to Sittwe Airport was initiated in marginal weather conditions with limited visibility due to low clouds. Following a radio contact with ATC, the pilot reported 3,500 feet on approach. Shortly later, the aircraft struck the slope of a hill (270 metres high) located 12 km short of runway 29. The aircraft was destroyed and all eight occupants were killed.
Probable cause:
Controlled flight into terrain after the crew descended below the MDA in IMC conditions.

Crash of a Piper PA-31T Cheyenne II in Deerfield: 1 killed

Date & Time: Jul 1, 1999 at 1402 LT
Type of aircraft:
Operator:
Registration:
N602RM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Jonesboro – Weyers Cave
MSN:
31-7920081
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1857
Captain / Total hours on type:
24.00
Aircraft flight hours:
4852
Circumstances:
The pilot was descending the airplane from 23,000 feet for an instrument approach. All communications were normal until after he acknowledged an instruction to contact approach control, when radio contact was lost. Radar contact ceased at 11,300 feet due to radar signal reception difficulties. Contact was lost almost directly over the eventual impact site, which was on the eastern side of a small valley. Witnesses on the western side of the valley had seen the airplane flying near them, at treetop level, eastbound, and clear of clouds. About the same time, on the eastern side of the valley where the airplane would impact trees, then terrain, there was heavy rain. The commercial pilot had about 1,850 total flight hours, and had completed a 'Wings III' flight proficiency program and an instrument proficiency program about two months earlier. The airplane had been on a continuous maintenance program. At the accident site, all of the airplane's control surfaces were found, and the engines and propellers displayed signatures consistent with being under power at impact. There were insufficient remains to conduct an autopsy or toxicological testing. Previously, the pilot's father, two uncles, and a male cousin had suffered fatal heart attacks.
Probable cause:
Loss of control of the airplane due to pilot incapacitation following a heart attack.
Final Report:

Crash of an Embraer EMB-110P2 Bandeirante in Goroka: 17 killed

Date & Time: Jun 17, 1999 at 0852 LT
Operator:
Registration:
P2-ALX
Survivors:
No
Site:
Schedule:
Lae - Goroka
MSN:
110-210
YOM:
1979
Flight number:
ND120
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
The twin engine aircraft departed Lae-Nadzab Airport at 0820LT on a flight to Goroka, carrying 15 passengers and two pilots. While descending in marginal weather conditions at an altitude of 8,500 feet, the aircraft struck the slope of a mountain located 20 km east-southeast of the airport. The aircraft was destroyed upon impact and all 17 occupants were killed, among them two Dutch citizens.
Probable cause:
Controlled flight into terrain after the crew continued the descent to Goroka under VFR mode in IMC conditions. At the time of the accident, the aircraft was one km off course and at an insufficient altitude (minimum altitude is fixed at 14,000 feet).

Crash of a De Havilland DHC-6 Twin Otter 300 near Málaga: 5 killed

Date & Time: Apr 8, 1999 at 1140 LT
Operator:
Registration:
HK-2760
Flight Phase:
Survivors:
No
Site:
Schedule:
Bucaramanga – Málaga
MSN:
777
YOM:
1981
Flight number:
ATK7655
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
3820
Captain / Total hours on type:
392.00
Copilot / Total flying hours:
966
Copilot / Total hours on type:
599
Aircraft flight hours:
34074
Aircraft flight cycles:
52799
Circumstances:
While descending to Málaga Airport, the crew encountered marginal weather conditions with low clouds and strong winds. The aircraft deviated from the prescribed approach path and entered a valley when the crew lost his orientation in clouds. At an altitude of 8,100 feet, the aircraft struck the slope of Mt La Carbonera shrouded in clouds. All five occupants were killed.
Probable cause:
Controlled flight into terrain after the crew continued the descent under VFR mode in IMC conditions.
Final Report:

Crash of a Douglas DC-3C near Tame: 8 killed

Date & Time: Mar 18, 1999 at 1630 LT
Type of aircraft:
Operator:
Registration:
HK-337
Flight Phase:
Survivors:
No
Site:
Schedule:
Cúcuta – Yopal
MSN:
11831
YOM:
1943
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
7838
Captain / Total hours on type:
7623.00
Copilot / Total flying hours:
1146
Copilot / Total hours on type:
940
Aircraft flight hours:
29475
Circumstances:
The twin engine aircraft departed Cúcuta-Camilo Daza Airport at 1533LT on a charter flight to Yopal, carrying five passengers, three crew members and a load of 2,500 kilos of various goods. About an hour into the flight, while cruising over the El Cocuy National Park, the aircraft encountered unfavorable currents, lost height and crashed in an isolated and mountainous area located about 45 km west of Tame. The wreckage was found on 12 April 1999 and all eight occupants were killed.
Probable cause:
Possible loss of control of the aircraft due to the presence of strong air currents or windshear, accompanied by extreme turbulences that caused the aircraft to lose height and struck the ground. Inadequate planning of the en route flight, overflying the mountain range apparently with the purpose of performing the operation in less time.
Final Report:

Crash of a Rockwell 500S Shrike Commander near San Cristóbal de Las Casas: 5 killed

Date & Time: Mar 18, 1999 at 0930 LT
Operator:
Registration:
ETL-1251
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
500-3211
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Terán AFB in Tuxtla Gutiérrez at 0915LT on a liaison flight, carrying three passengers and two pilots. About 15 minutes later, the aircraft struck the slope of Mt Tzontehuitz located about 12 km northeast of San Cristóbal de Las Casas. All five occupants were killed.

Crash of a Beechcraft C99 Airliner near Bishop: 1 killed

Date & Time: Feb 12, 1999 at 1030 LT
Type of aircraft:
Operator:
Registration:
N205RA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tonopah - Bishop
MSN:
U-205
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2958
Captain / Total hours on type:
692.00
Aircraft flight hours:
20522
Circumstances:
The airline transport pilot was repositioning the Beech C99 turboprop cargo hauler on a 73-mile trip without cargo. The pilot had been flying this route for some time and this was his last trip before upgrading to a larger aircraft and route. He told friends that he would take pictures of the scenic parts of the route on his last trip. Three witnesses reported seeing the airplane flying west at low altitude. Two of the witnesses were local ranchers who saw the airplane enter the White Mountains near Trace Plumas Canyon about 7,000 to 8,000 feet msl. White Mountain is 14,246 feet, tapering off north to 13,559 feet and south to 11,285 feet msl. The airplane was reported missing and 2 days later located on White Mountain about 9,400 feet msl. The company flight planned route is 15 miles south of the accident site through Westgard Pass, about 7,291 feet msl. Examination of the low energy impact and the subsequent recovery inspection failed to reveal any mechanical issues.
Probable cause:
The pilot's failure to follow procedures and directives and his failure to maintain clearance from mountainous terrain.
Final Report:

Crash of a Douglas DC-3C in Mayne Island: 2 killed

Date & Time: Jan 13, 1999 at 0633 LT
Type of aircraft:
Operator:
Registration:
C-GWUG
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Vancouver - Victoria
MSN:
16215/32963
YOM:
1945
Flight number:
KFA301
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
18000
Captain / Total hours on type:
9500.00
Copilot / Total flying hours:
9000
Copilot / Total hours on type:
430
Aircraft flight hours:
20123
Circumstances:
The accident aircraft, a Douglas DC-3C, C-GWUG, was owned and operated by Kelowna Flightcraft Air Charter Ltd. (Kelowna Flightcraft) and was under charter to Purolator Courier Ltd. (Purolator). Since April 1998, the aircraft had been dedicated to transporting cargo on a route between Vancouver and Nanaimo, British Columbia. On occasion, it was also used for flights to Victoria to meet Purolator=s scheduling or cargo-loading contingencies. On the day of the accident, the aircraft, operating as KFA300, was rerouted and tasked to fly from Vancouver to Victoria and then proceed to Nanaimo. This change was precipitated by the delayed arrival of Purolator=s Boeing 727 at Vancouver because of inclement weather in the Toronto/Hamilton, Ontario, area. Warning of this route change was passed to the crew members with their pre-flight planning package, which included filed instrument flight rules (IFR) flight plans for the Vancouver-to-Victoria and Victoria-to-Nanaimo legs of the trip. The captain of the occurrence flight cancelled his IFR flight plan and refiled visual flight rules (VFR) on first contact with air traffic control. Vancouver tower cleared KFA300 for take-off at 0622 Pacific standard time (PST) from runway 26L. After take-off, the aircraft turned left on a track toward Active Pass, as seen in Figure 1. During the departure climb, the captain requested an altitude of 1000 feet above sea level (asl); the tower controller approved this request. Recorded radar data indicate that the aircraft climbed to and levelled at 1000 feet asl and then accelerated to a steady en route ground speed of 130 knots. The aircraft left the Vancouver control zone at 0626 and entered Class E (controlled) airspace. There are no special requirements for VFR aircraft operating within this class of airspace, nor are any specific services required of the air traffic control system. As the aircraft approached the Gulf Islands, it descended slightly and remained level at 900 feet asl. It crossed about 0.25 nautical mile (nm) west of the Active Pass non-directional beacon (NDB) at 0632 while remaining steady at 130 knots (ground speed) and level at 900 feet asl. At 0633:04, the aircraft descended to 800 feet asl for about nine seconds. The last radar data show the aircraft at 900 feet asl and 130 knots. The last radar-depicted position of the aircraft is on a bearing of 189 degrees (true) and 21.8 nm from the Sea Island radar source, coincident with the crash location.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The accident flight was not conducted in accordance with the night obstacle clearance requirements of Canadian Aviation Regulation (CAR) 705.32.
2. The Kelowna Flightcraft company operations manual did not reflect the restrictive conditions imposed on night visual flight rules (VFR) flight by CAR 705.32. Such information might have
prevented the accident by ensuring the crew's awareness of those night obstacle clearance standards.
3. As the aircraft approached Mayne Island, it encountered a low cloud ceiling that was based about 800 feet and that reduced visual reference with the surface.
4. When the aircraft struck trees, it was being flown in controlled, level flight at an altitude below the surrounding terrain.
5. The aircraft was not equipped with a ground proximity warning system or any other similar system that could warn the crew of an impending collision with terrain. Such systems were not required by regulation.
Findings as to Risk:
1. Kelowna Flightcraft flight operations personnel were not aware that most of the DC-3 flights were being conducted under VFR.
2. First responders were not aware of the presence of the dangerous goods and were therefore at increased risk during their response activities on the site.
Other Findings:
1. Transport Canada officials responsible for monitoring this operation were not aware that most of the DC-3 flights were being conducted under VFR at night and below the required obstacle
clearance altitudes.
Final Report: