Country
Crash of a Beechcraft B200 Super King Air in Blackbushe: 5 killed
Date & Time:
Dec 23, 2000 at 1351 LT
Operator:
Registration:
VP-BBK
Survivors:
No
Schedule:
Blackbush - Palma de Mallorca
MSN:
BB-1519
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total hours on type:
1243.00
Circumstances:
The aircraft, with the pilot and four passengers on board, departed Blackbushe from Runway 08 in fog with a visibility of less than 500 metres. As the aircraft reached the upwind end of the runway it was seen to bank to the left before disappearing from view. It crashed 13 seconds later into a factory complex where a major fire ensued. All on board were fatally injured. A substantial amount of the aircraft structure was consumed by fire. Engineering examination of that which remained showed that there was no malfunction found within the engines, propellers or controls that would have affected the flight. Analysis of the cockpit voice recorder however showed a reduction in one of the propellers rpm as the aircraft rotated that would have led to thrust asymmetry. Through a combination of lack of visual reference, confusion as to the cause of the power reduction and possible disorientation the pilot lost control of the aircraft and although he may have realised the situation seconds before impact with the ground there was insufficient height available to effect a safe recovery.
Probable cause:
Whilst the CVR does not provide any comments by the pilot as to the problems he was experiencing, spectral analysis of the CVR recording indicates that a significant difference in propeller rpm occurred at rotation when the pilot would normally have removed his right hand from the power levers. There was no evidence of a malfunction in either engine or the propeller control systems thus it is probable that migration of a power lever(s) occurred due to insufficient friction being set on the power lever friction control. The fiction control had been slackened during recent maintenance and it was possible that it was not adjusted sufficiently by the pilot during his checks prior to takeoff. His simulator training had included engine failures but as far as could be established, the pilot had not encountered or been trained for the situation of power lever(s) migration during takeoff. With his level of experience the pilot should have controlled the resultant asymmetric thrust and in reasonable conditions continued the takeoff to a safe height where analysis of the problem could have been carried out. In the event the takeoff was carried out in extremely low visibility conditions leading to the pilot's total loss of any ground references within seconds of lift off. Having controlled the aircraft initially the lack of visual reference with the ground, possible confusion with attitude instrument bank angle display, physical disorientation brought about by cockpit activity and confusion as to the exact nature of the problem led the pilot to lose control of the aircraft at a low altitude. The unusual attitude developed by the aircraft and the reason for the power asymmetry may have been recognised by the pilot several seconds before impact however there was insufficient height available for him to effect a safe recovery. The transition from visual to instrument flight in the low visibility conditions existing at the time of departure was considered to be a major contributory factor in this accident.
Final Report:
Crash of a Beechcraft B200 Super King Air in Rangeley: 2 killed
Date & Time:
Dec 22, 2000 at 1716 LT
Registration:
N30EM
Survivors:
No
Schedule:
Rangeley – Boston – Portland – Rangeley
MSN:
BB-958
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
8845
Circumstances:
The pilot and passenger departed on a night IFR flight. Weather en route was a mixture of instrument and visual meteorological conditions. When the airplane was 17 miles southwest of its destination, the pilot was cleared for an instrument approach. At 9 miles, the pilot reported the airport in sight, and canceled his IFR clearance. The airplane continued to descend towards the airport on a modified left base until radar contact was lost at 3,300 feet msl. The pilot was in radio contact with his wife just prior to the accident. He advised her that he was on base for runway 32. Neither the pilot's wife, nor ATC received a distress call from the pilot. The airplane was located the next morning about 100 feet below the top of a mountain. The accident site was 7.9 miles from the airport, and approximately 1,200 feet above the airport elevation. Ground based weather radar recorded light snow showers, in the general vicinity of the accident site about the time of the accident, and satellite imagery showed that the airplane was operating under a solid overcast. A level path was cut through the trees that preceded the main wreckage. Examination of both engines and the airframe revealed no pre impact failures or malfunctions.
Probable cause:
The pilot-in-command's failure to maintain sufficient altitude while maneuvering to land, which resulted in a collision with terrain. Factors in the accident were the dark night, mountainous terrain, snow showers, clouds, and the pilot's decision to cancel his IFR clearance.
Final Report:
Crash of a Beechcraft 200 Super King Air in Wernadinga Station: 8 killed
Date & Time:
Sep 4, 2000 at 1510 LT
Registration:
VH-SKC
Survivors:
No
Schedule:
Perth - Leonora
MSN:
BB-47
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total hours on type:
138.00
Aircraft flight hours:
18771
Circumstances:
On 4 September 2000, a Beech Super King Air 200 aircraft, VH-SKC, departed Perth, Western Australia at 1009 UTC on a charter flight to Leonora with one pilot and seven passengers on board. Until 1032 the operation of the aircraft and the communications with the pilot appeared normal. However, shortly after the aircraft had climbed through its assigned altitude, the pilot’s speech became significantly impaired and he appeared unable to respond to ATS instructions. Open microphone transmissions over the next 8-minutes revealed the progressive deterioration of the pilot towards unconsciousness and the absence of any sounds of passenger activity in the aircraft. No human response of any kind was detected for the remainder of the flight. Five hours after taking off from Perth, the aircraft impacted the ground near Burketown, Queensland, and was destroyed. There were no survivors.
Probable cause:
Due to the limited evidence available, it was not possible to draw definitive conclusions as to the factors leading to the incapacitation of the pilot and occupants of VH-SKC.
The following findings were identified:
1. The pilot was correctly licensed, had received the required training, and there was no evidence to suggest that he was other than medically fit for the flight.
2. The weather conditions on the day presented no hazard to the operation of the aircraft on its planned route.
3. The flightpath flown was consistent with the aircraft being controlled by the autopilot in heading and pitch-hold modes with no human intervention after the aircraft passed position DEBRA.
4. After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia.
5. Testing revealed that Carbon Monoxide and Hydrogen Cyanide were highly unlikely to have been factors in the occurrence.
6. The low Carbon Monoxide and Cyanide levels, and the absence of irritation in the airways of the occupants indicated that a fire in the cabin was unlikely.
7. The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen.
8. A rapid or explosive depressurisation was unlikely to have occurred.
9. The reasons for the pilot and passengers not receiving supplemental oxygen could not be determined.
10. Setting the visual alert to operate when the cabin pressure altitude exceeds 10,000 ft and incorporating an aural warning in conjunction with the visual alert, may have prevented the accident.
11. The training and actions of the air traffic controller were not factors in the accident.
Significant factors:
1. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons.
2. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen.
The following findings were identified:
1. The pilot was correctly licensed, had received the required training, and there was no evidence to suggest that he was other than medically fit for the flight.
2. The weather conditions on the day presented no hazard to the operation of the aircraft on its planned route.
3. The flightpath flown was consistent with the aircraft being controlled by the autopilot in heading and pitch-hold modes with no human intervention after the aircraft passed position DEBRA.
4. After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia.
5. Testing revealed that Carbon Monoxide and Hydrogen Cyanide were highly unlikely to have been factors in the occurrence.
6. The low Carbon Monoxide and Cyanide levels, and the absence of irritation in the airways of the occupants indicated that a fire in the cabin was unlikely.
7. The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen.
8. A rapid or explosive depressurisation was unlikely to have occurred.
9. The reasons for the pilot and passengers not receiving supplemental oxygen could not be determined.
10. Setting the visual alert to operate when the cabin pressure altitude exceeds 10,000 ft and incorporating an aural warning in conjunction with the visual alert, may have prevented the accident.
11. The training and actions of the air traffic controller were not factors in the accident.
Significant factors:
1. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons.
2. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen.
Final Report:
Crash of a Beechcraft B200 Super King Air in Spanish Cay
Date & Time:
Aug 12, 2000 at 1115 LT
Registration:
N3199A
Survivors:
Yes
Schedule:
Fort Lauderdale – Spanish Cay
MSN:
BB-1499
YOM:
1995
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On August 12, 2000, about 1115 eastern daylight time, a Beechcraft B200, N3199A, registered to and operated by Great Texas Food Inc. as a Title 14 CFR Part 91 personal flight, ran off the side of the runway during landing in Spanish Cay, Bahamas. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed. The private-rated pilot and the two passengers received no injuries. The flight originated from Fort Lauderdale, Florida, the same day, about 1030. The pilot stated that he made an uneventful landing and as he applied the brakes, the left brake did not respond. He stated that he lost control of the aircraft and exited the runway from the right side and impacted a berm. The right landing gear collapsed, the left wing and the front fuselage incurred substantial damage.
Crash of a Beechcraft B200C Super King near Kulu-Bhuntar: 5 killed
Date & Time:
Jul 29, 2000 at 1332 LT
Registration:
VT-EIE
Survivors:
No
Schedule:
New Delhi – Kulu-Bhuntar
MSN:
BL-63
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total hours on type:
776.00
Aircraft flight hours:
6243
Aircraft flight cycles:
5646
Circumstances:
The twin engine aircraft departed New Delhi-Indira Gandhi Airport on an ambulance flight to Kulu-Bhuntar, carrying three doctors and two pilots. While descending to Kulu-Bhuntar Airport in IMC conditions, the crew failed to realize his altitude was insufficient when the aircraft struck the slope of a mountain located 20 km from the destination airport. The aircraft was destroyed and all five occupants were killed.
Probable cause:
The pilot descended below minimum sector altitude in Instrument Meteorological Condition in hilly area.
Contributing factors were:
1. ATC Chandigarh contributed to the accident by permitting IFR flight to descend below minimum sector altitude.
2. Inadequate Supervision, Lack of Safety culture and poor pre-flight planning. Factor: Pilot: Non-adherence to standard operating procedure.
Contributing factors were:
1. ATC Chandigarh contributed to the accident by permitting IFR flight to descend below minimum sector altitude.
2. Inadequate Supervision, Lack of Safety culture and poor pre-flight planning. Factor: Pilot: Non-adherence to standard operating procedure.
Final Report:
Crash of a Beechcraft 200 Super King Air in the Pacific Ocean
Date & Time:
May 23, 2000 at 1945 LT
Registration:
N24CV
Survivors:
Yes
Schedule:
Parker – Carlsbad
MSN:
BB-1524
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
1058.00
Aircraft flight hours:
1350
Circumstances:
En route from Arizona to California, the pilot became nauseous and began to vomit. The pilot advised air traffic that he was sick and radio contact was lost. The airplane had descended from 16,500 feet msl and was on an established course to his destination and level at 10,500 feet msl being flown by the autopilot. The last thing that he recalled was approaching his destination. When the pilot regained consciousness he looked outside the airplane to determine where he was. The surface was obscured in cloud cover. On his left side was a Navy F18 fighter plane, and they briefly communicated by hand signals. The F18 pilot indicated he should turn around towards land. The accident pilot determined that he was 186 nautical miles southwest of his destination and over the ocean. He reversed his course. The pilot attempted to contact air traffic without success; another aircraft relayed the pilot's message to air traffic. The pilot declared a medical emergency and advised that because of low fuel he would not be able to return to land. Within 10 minutes the fuel onboard was exhausted and the pilot configured the airplane for the best angle of glide and ditching at sea. Subsequently, the pilot descended through low stratus and ditched the airplane in the ocean at dusk. The pilot exited the airplane with a hand held VHF radio, two flashlights, a cell phone, and a trash bag for flotation; he climbed onto the top of the fuselage to await rescue. At this time it was dark. After about 30 minutes a Navy S3B circled the downed plane until a rescue helicopter arrived and rescued him. While at the pilot's Arizona residence he sprayed for bugs and insects using the pesticide 'Dursban.' During the process he opened the spray container to replenish the pesticide and the built-up pressure sprayed the vapor into his face. He cleaned himself up and then departed for the airport and the return flight to Palomar. He had bought food to eat during the flight, and shortly thereafter, he became sick in flight. The EPA as of June 8, 2000, has banned Dursban from the commercial market.
Probable cause:
Physical incapacitation of the pilot from improper handling of a pesticide.
Final Report:
