Country
Crash of a Beechcraft 1900C-1 in Lubango: 16 killed
Date & Time:
Mar 17, 2001 at 0823 LT
Operator:
Registration:
S9-CAE
Survivors:
Yes
Schedule:
Luanda – Lubango
MSN:
UC-142
YOM:
1991
Crew on board:
2
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
16
Circumstances:
While descending to Lubango Airport following an uneventful flight from Luanda, the crew encountered poor weather conditions with heavy rain falls and low ceiling. In such conditions, the aircraft struck the slope of a mountain located 16 km northwest of runway 10 threshold. One passenger survived while 16 other occupants were killed.
Probable cause:
A possible loss of control after the pilot-in-command suffered a spatial disorientation while descending in IMC conditions.
Crash of a Beechcraft 1900C-1 in Moanda: 3 killed
Date & Time:
May 18, 2000 at 0947 LT
Operator:
Registration:
TR-LFK
Survivors:
Yes
Schedule:
Libreville - Moanda
MSN:
UC-133
YOM:
1990
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Libreville on a charter flight to Moanda, carrying employees of the Société d’Électricité et d’Énergie du Gabon (S.E.E.G.). While approaching Moanda, the crew was cleared to descent to 4,100 feet and encountered poor visibility due to fog. On short final, the aircraft struck the ground and crashed 1,600 metres short of runway 14. A pilot and two passengers were killed while seven other occupants were injured.
Probable cause:
Controlled flight into terrain after the crew continued the approach after passing the MDA until the aircraft impacted ground. Poor visibility due to foggy conditions was a contributing factor.
Crash of a Beechcraft 1900C-1 in Saint Mary's
Date & Time:
Feb 11, 1999 at 2345 LT
Operator:
Registration:
N31240
Survivors:
Yes
Schedule:
Anchorage – Saint Mary’s
MSN:
UC-28
YOM:
1988
Flight number:
AER91
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1587.00
Aircraft flight hours:
19588
Circumstances:
The airline transport pilot was cleared for the localizer approach. The airplane impacted the ground 3.2 nautical miles from the runway threshold. The minimum descent altitude (MDA) for the approach was 560 feet msl, which is 263 feet above touchdown. Night, instrument meteorological conditions prevailed at the time of the accident. The surrounding terrain was flat, snow-covered, and featureless. The reported weather was 200 feet overcast, 1 1/2 miles visibility in snow, and winds of 12 knots, gusting to 32 knots. The pilot reported he was established on the final approach course, descending to the MDA, and then woke up in the snow. He said he did not remember any problems with the airplane. No pre accident mechanical anomalies were discovered with the airplane during the investigation. The airport has high intensity runway lights, sequenced flashing lead-in lights, and visual approach slope indicator lights. All airport lights and navigation aids were functioning. The airplane was not equipped with an autopilot. Captains have the option of requesting a copilot, but, the captain's pay is reduced by a portion equal to one-half the copilot's pay. The pilot had returned from the previous nights trip at 0725. He had three rest periods, four hours, two hours, and five hours 15 minutes, since his previous nights flight. Each rest period was interrupted by contact with the company. The company indicated that it is the pilot's responsibility to tell the company if duty times are being exceeded. 14 CFR 135.267 states, in part: '(d) Each assignment ... must provide for at least 10 consecutive hours of rest during the 24 hours that precedes the planned completion of the assignment.'
Probable cause:
The pilot's descent below the minimum descent altitude on the instrument approach. Factors were pilot fatigue resulting from the pilot's rest period being interrupted by scheduling discussions and the night weather conditions of low ceilings and whiteout.
Final Report:
Crash of a Beechcraft 1900C-1 off Saint-Augustin
Date & Time:
Jan 4, 1999 at 0859 LT
Operator:
Registration:
C-FGOI
Survivors:
Yes
Schedule:
Lourdes-de-Blanc-Sablon – Saint-Augustin
MSN:
UC-085
YOM:
1989
Flight number:
RH1707
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Copilot / Total hours on type:
500
Circumstances:
The Régionnair Inc. Beechcraft 1900C, serial number UC-85, with two pilots and 10 passengers on board, was making an instrument flight rules (IFR) flight between Lourdes-de-Blanc-Sablon, Quebec, and Saint-Augustin, Quebec. Just before initiation of descent, the radiotelephone operator of the Saint-Augustin Airport UNICOM (private advisory service) station informed the crew that the ceiling was 300 feet, visibility a quarter of a mile in snow flurries, and the winds from the southeast at 15 knots gusting to 20 knots. The crew made the LOC/DME (localizer transmitter / distance-measuring equipment) non-precision approach for runway 20. The approach proceeded normally until the minimum descent altitude (MDA). When the first officer reported sighting the ground beneath the aircraft, the captain decided to continue descending below the MDA. Thirty-five seconds later, the ground proximity warning system (GPWS) AMINIMUMS@ audible alarm sounded. Three seconds later, the aircraft flew into the frozen surface of the Saint-Augustin River. The occupants escaped the accident unharmed. The aircraft was heavily damaged.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.
1. The crew did not follow the company's SOPs for the briefing preceding the approach and for a missed approach.
2. In the approach briefing, the captain did not specify the MDA or the MAP, and the first officer did not notice these oversights, which shows a lack of coordination within the crew.
3. The captain continued descent below the MDA without establishing visual contact with the required references.
4. The first officer probably had difficulty perceiving depth because of the whiteout.
5. The captain did not effectively monitor the flight parameters because he was trying to establish visual contact with the runway.
6. The chief pilot (the captain of C-FGOI) set a bad example to the pilots under him by using a dangerous method, that is, descending below the MDA without establishing visual contact with the required references and using the GPWS to approach the ground.
Findings as to Risks:
1. The operations manager did not effectively supervise air operations.
2. Transport Canada did not detect the irregularities that compromised the safety of the flight before the occurrence.
3. Régionnair had not developed GPWS SOPs for non-precision approaches.
Other Findings:
1. The GPWS 'MINIMUMS' alarm sounded at a height that did not leave the captain time to initiate pull-up and avoid striking the ground because of the aircraft=s rate of descent and other flight
parameters.
2. Neither the captain nor the first officer had received PDM training or CRM training.
3. At the time of the approach, the ceiling and visibility unofficially reported by the AAU were below the minima published on the approach chart.
4. The decision to make the approach was consistent with existing regulations because runway 02/20 was not under an approach ban.
5. Some Régionnair pilots would descend below the MDA and use the GPWS to approach the ground if conditions made it impossible to establish visual contact with the required references.
Final Report:
