Crash of a BAe 3101 Jetstream 31 in Skien

Date & Time: Nov 30, 2001 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LGA
Survivors:
Yes
Schedule:
Bergen - Skien
MSN:
636
YOM:
1984
Flight number:
EXC204
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6590
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
1700
Copilot / Total hours on type:
390
Aircraft flight hours:
14074
Aircraft flight cycles:
16666
Circumstances:
The aircraft was on its way to Skien with a crew of two and 11 passengers. During the flight, ice was observed on the aircraft’s wings, but the ice was considered to be too thin to be removed. During descent towards runway 19 at Geiteryggen the aircraft’s ground proximity warning system (GPWS) sounded a total of three times. The aircraft was then in clouds and the crew did not have visual contact with the ground. The warnings, combined with somewhat poorly functioning crew coordination, resulted in the crew forgetting to actuate the system for removing ice from the wings. The subsequent landing at 1828 hrs was unusually hard, and several of the passengers thought that the aircraft fell the last few metres onto the runway. The hard landing caused permanent deformation of the left wing so that the left-hand landing gear was knocked out of position, and the left propeller grounded on the runway. The crew lost directional control and the aircraft skewed to the left and ran off the runway. The aircraft then hit a gravel bank 371 metres from the touchdown point. The collision with the gravel bank was so hard that the crew and several of the passengers were injured and the aircraft was a total loss. It was dark, light rain and 4 °C at Geiteryggen when the accident occurred. The wind was stated to be 120° 10 kt. The investigation shows that it is probable that ice on the wings was the initiating factor for the accident. The AIBN has not formed an opinion on whether the ice resulted in the high sink rate after the first officer reduced the power output of the engines, or whether the aircraft stalled before it hit the runway. Investigation has to a large extend focused on the crew composition and training. A systematic investigation of the organisation has also taken place. In the opinion of the AIBN, the company has principally based its operations on minimum standards, and this has resulted in a number of weaknesses in organisation, procedures and quality assurance. These conditions have indirectly led to the company operating the route Skien – Bergen with a crew that, at times, did not maintain the standard that is expected for scheduled passenger flights. The investigation has also revealed that procedures for de-icing of the aircraft wings could be improved.
Probable cause:
Significant investigation results:
a) The decision was made to wait to remove the ice from the wings because, according to the SOP, it should only be removed if it had been “typically half an inch on the leading edge”. This postponement was a contributory factor in the ice being forgotten.
b) At times, the relationship between the flight crew members was very tense during the approach to Skien. This led to a breakdown in crew coordination.
c) Among the consequences of the warnings from the GPWS was a very high workload for the crew. In combination with the defective crew coordination, this contributed to the ice on the wings being forgotten.
d) It is probable that the aircraft hit the runway with great force because the wings were contaminated with ice. The AIBN is not forming a final opinion on whether the wings stalled, whether the aircraft developed a high sink rate due to ice accretion or whether the hard landing was due to a combination of the two explanatory models.
e) The company could only provide documentary evidence to show that the Commander had attended an absolute minimum of training after being employed within the company. Parts of the mandatory training had taken place by means of self-study without any form of formal verification of achievement of results.
f) The company’s operation was largely based on minimum solutions. This reduced the safety margins within company operations.
g) The company’s quality system contributed little to ensuring ‘Safe Operational Practices’ in the company.
h) Authority inspection of the company was deficient.
Final Report:

Crash of a BAe 3201 Jetstream 32EP near Chulum Juárez: 19 killed

Date & Time: Jul 8, 2000 at 1950 LT
Type of aircraft:
Operator:
Registration:
N912FJ
Flight Phase:
Survivors:
No
Site:
Schedule:
Tuxtla Gutiérrez – Villahermosa – Veracruz – Mérida
MSN:
912
YOM:
1990
Flight number:
QA7831
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
5300
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
667
Copilot / Total hours on type:
40
Aircraft flight hours:
12041
Circumstances:
The aircraft departed Tuxtla Gutiérrez Airport on a regular schedule flight to Mérida with intermediate stops in Villahermosa and Veracruz, carrying 17 passengers and two pilots. En route to Villahermosa-Carlos Rovirosa Pérez Airport, at an altitude of 16,000 feet and about 50 miles from the destination, the crew encountered poor weather conditions and deviated from the V3 Airway to the right for about 24 km. After he initiated the descent, the crew was instructed by ATC to report 25 DME. Shortly later, while descending in clouds, the twin engine aircraft struck the slope of a mountain located near Chulum Juárez, about 80 km southeast of Villahermosa Airport. The wreckage was found at an altitude of 1,890 metres. The aircraft disintegrated on impact and all 19 occupants were killed.
Probable cause:
Controlled flight into terrain. Combining instrument flight (IFR), with visual flight (VFR), the crew lost situational awareness, deviating 29.8 miles to the right of the Victor 3 airway due to bad weather, when the weather conditions imposed the application of the instrument flight rules (IFR), causing collision of the aircraft with the mountain at 6200 feet of elevation without loss of control (CFIT).
The following contributing factors were identified:
- Severe weather conditions en route,
- Persistence of the pilot in command, to continue the instrument flight (IFR) on visual flight (VFR),
- Inconsistency in cockpit resource management (CRM),
- Loss of situational awareness of the flight crew and the controllers, due to numerous deviations from the route, due to severe weather conditions and poor communication between the parties.
- inadequate preparation of the flight plan, since in view of the very probable need to circumnavigate severe meteorological conditions, the flight altitudes that would continue outside of the controlled airspace (outside the v-3 airway) were not verified.
Final Report:

Crash of a BAe Jetstream 31 in Wilkes-Barre: 19 killed

Date & Time: May 21, 2000 at 1148 LT
Type of aircraft:
Operator:
Registration:
N16EJ
Survivors:
No
Schedule:
Atlantic City – Wilkes-Barre
MSN:
834
YOM:
1988
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
8500
Captain / Total hours on type:
1874.00
Copilot / Total flying hours:
1282
Copilot / Total hours on type:
742
Aircraft flight hours:
13972
Aircraft flight cycles:
18503
Circumstances:
On May 21, 2000, about 1128 eastern daylight time (EDT), a British Aerospace Jetstream 3101, N16EJ, operated by East Coast Aviation Services (doing business as Executive Airlines) crashed
about 11 miles south of Wilkes-Barre/Scranton International Airport (AVP), Wilkes-Barre, Pennsylvania. The airplane was destroyed by impact and a post crash fire, and 17 passengers and two flight crewmembers were killed. The flight was being conducted under 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight for Caesar’s Palace Casino in Atlantic City, New Jersey. An instrument flight rules (IFR) flight plan had been filed for the flight from Atlantic City International Airport (ACY) to AVP. The captain checked in for duty about 0800 at Republic Airport (FRG) in Farmingdale, New York, on the day of the accident. The airplane was originally scheduled to depart FRG at 0900 for ACY and to remain in ACY until 1900, when it was scheduled to return to FRG. While the pilots were conducting preflight inspections, they received a telephone call from Executive Airlines’ owner and chief executive officer (CEO) advising them that they had been assigned an additional flight from ACY to AVP with a return flight to ACY later in the day, instead of the scheduled break in ACY. Fuel records at FRG indicated that 90 gallons of fuel were added to the accident airplane’s tanks before departure to ACY. According to Federal Aviation Administration (FAA) air traffic control (ATC) records, the flight departed at 0921 (with 12 passengers on board) and arrived in ACY at 0949. According to passenger statements, the captain was the pilot flying from FRG to ACY. After arrival in ACY, the flight crew checked the weather for AVP and filed an IFR flight plan. Fuel facility records at ACY indicated that no additional fuel was added. The accident flight to AVP, which departed ACY about 1030, had been chartered by Caesar’s Palace. According to ATC records, the flight to AVP was never cleared to fly above 5,000 feet mean sea level (msl). According to ATC transcripts, the pilots first contacted AVP approach controllers at 1057 and were vectored for an instrument landing system (ILS) approach to runway 4. The flight was cleared for approach at 1102:07, and the approach controller advised the pilots that they were 5 nautical miles (nm) from Crystal Lake, which is the initial approach fix (IAF) for the ILS approach to runway 4. The pilots were told to maintain 4,000 feet until established on the localizer. At 1104:16, the approach controller advised that a “previous landing…aircraft picked up the airport at minimums [decision altitude].” The pilots were instructed to contact the AVP local (tower) controller at 1105:09, which they did 3 seconds later. The airplane then descended to about 2,200 feet, flew level at 2,200 feet for about 20 seconds, and began to climb again about 2.2 nm from the runway threshold when a missed approach was executed (see the Airplane Performance section for more information). At 1107:26 the captain reported executing the missed approach but provided no explanation to air traffic controllers. The tower controller informed the North Radar approach controllers of the missed approach and then instructed the accident flight crew to fly runway heading, climb to 4,000 feet, and contact approach control on frequency 124.5 (the procedure published on the approach chart). The pilots reestablished contact with the approach controllers at 1108:04 as they climbed through 3,500 feet to 4,000 feet and requested another ILS approach to runway 4. The flight was vectored for another ILS approach, and at 1110:07 the approach controller advised the pilots of traffic 2 nm miles away at 5,000 feet. The captain responded that they were in the clouds. At 1014:38, the controller directed the pilots to reduce speed to follow a Cessna 172 on approach to the airport, and the captain responded, “ok we’re slowing.” The flight was cleared for a second approach at 1120:45 and advised to maintain 4,000 feet until the airplane was established on the localizer. At 1123:49 the captain transmitted, “for uh one six echo juliet we’d like to declare an emergency.” At 1123:53, the approach controller asked the nature of the problem, and the captain responded, “engine failure.” The approach controller acknowledged the information, informed the pilots that the airplane appeared to be south of the localizer (off course to the right), and asked if they wanted a vector back to the localizer course. The flight crew accepted, and at 1124:10 the controller directed a left turn to heading 010, which the captain acknowledged. At 1124:33, the controller asked for verification that the airplane was turning left. The captain responded, “we’re trying six echo juliet.” At 1124:38, the controller asked if a right turn would be better. The captain asked the controller to “stand by.” At 1125:07, the controller advised the pilots that the minimum vectoring altitude (MVA) in the area was 3,300 feet. At 1125:12, the captain transmitted, “standby for six echo juliet tell them we lost both engines for six echo juliet.” At that time, ATC radar data indicated that the airplane was descending through 3,000 feet. The controller immediately issued the weather conditions in the vicinity of the airport and informed the flight crew about the location of nearby highways. At 1126:17, the captain asked, “how’s the altitude look for where we’re at.” The controller responded that he was not showing an altitude readout from the airplane and issued the visibility (2.5 miles) and altimeter setting. At 1126:43, the captain transmitted, “just give us a vector back to the airport please.” The controller cleared the accident flight to fly heading 340, advised the flight crew that radar contact was lost, and asked the pilots to verify their altitude. The captain responded that they were “level at 2,000.” At 1126:54, the controller again advised the flight crew of the 3,300-foot MVA and suggested a 330° heading to bring the airplane back to the localizer. At 1127:14 the controller asked, “do you have any engines,” and the captain responded that they appeared to have gotten back “the left engine now.” At 1127:23, the controller informed the pilots that he saw them on radar at 2,000 feet and that there was a ridgeline between them and the airport. The captain responded, “that’s us” and “we’re at 2,000 feet over the trees.” The controller instructed the pilots to fly a 360° heading and advised them of high antennas about 2 nm west of their position. At 1127:46, the captain transmitted, “we’re losing both engines.” Two seconds later the controller advised that the Pennsylvania Turnpike was right below the airplane and instructed the flight crew to “let me know if you can get your engines back.” There was no further radio contact with the accident airplane. The ATC supervisor initiated emergency notification procedures. A Pennsylvania State Police helicopter located the wreckage about 1236, and emergency rescue units arrived at the accident site about 1306. The accident occurred in daylight instrument meteorological conditions (IMC). The location of the accident was 41° 9 minutes, 23 seconds north latitude, 75° 45 minutes, 53 seconds west longitude, about 11 miles south of the airport at an elevation of 1,755 feet msl.
Probable cause:
The flight crew’s failure to ensure an adequate fuel supply for the flight, which led to the stoppage of the right engine due to fuel exhaustion and the intermittent stoppage of the left engine due to fuel starvation. Contributing to the accident were the flight crew's failure to monitor the airplane’s fuel state and the flight crew's failure to maintain directional control after the initial engine stoppage.
Final Report: