Crash of a Britten-Norman BN-2A-26 Islander in Saint John's: 3 killed

Date & Time: Oct 7, 2012 at 1610 LT
Type of aircraft:
Operator:
Registration:
VP-MON
Flight Phase:
Survivors:
Yes
Schedule:
Saint John’s – Montserrat
MSN:
82
YOM:
1969
Flight number:
MNT107
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
710
Captain / Total hours on type:
510.00
Aircraft flight hours:
22064
Aircraft flight cycles:
55851
Circumstances:
The aircraft was operating a VFR scheduled commercial air transport flight from VC Bird International Airport, Antigua (TAPA), to John A Osborne Airport, Montserrat (TRPG). The accident occurred during the aircraft’s fourth sector of the day. Prior to the accident flight, another pilot had flown two sectors in it, from John A Osborne to VC Bird and return, before going off duty. The accident pilot reported for duty at 1130 hrs, completed pre-flight preparations, and operated the aircraft to VC Bird. After the aircraft’s arrival at VC Bird, the airport closed to VFR traffic because of cumulonimbus activity and heavy rain. The airport re-opened for VFR operations shortly before the aircraft’s departure. A cumulonimbus cloud was present on the approach to Runway 07, and although the surface wind was westerly, Runway 07 was in use for departures. On board the aircraft were the pilot, three passengers, and bags weighing 150 lb. The fuel load on departure was 65 USG of AVGAS. The takeoff mass was shown on the load sheet as 5,540 lb, which was below the structural maximum takeoff weight of 6,600 lb; the performance-regulated takeoff weight at the ambient temperature of 24 °C was greater than the structural limit. The passengers and pilot travelled in a bus from the airport terminal to the aircraft. The passengers boarded the aircraft, and the baggage was loaded into the compartment behind the rear-most seats. The pilot then boarded the aircraft. The pilot was not observed to carry out a drain of the fuel system’s water traps (the operations manual did not stipulate that a drain check should be carried out). The pilot called the VC Bird Ground Movement Control (GMC) controller for permission to start engines, and was instructed to wait while the controller contacted Montserrat ATC to enquire about the weather there. The pilot then asked for surface wind information for VC Bird and was informed it was from 240° at 10 kts. The controller gave permission for start and passed the Montserrat weather, which was suitable for the operation. The pilot was instructed to taxi to holding position Bravo. The pilot contacted the Tower controller and was instructed to enter, backtrack, and line up on Runway 07. The controller described the weather observed from the Tower to the pilot, and the pilot requested a left-hand turn-out after departure. The surface wind was transmitted as from 270° at 10 kts and the aircraft was cleared for takeoff. The aircraft entered the runway at Bravo but did not backtrack. No power checks were carried out (other evidence indicated that power checks were routinely not carried out other than on each pilot’s first flight of the day). The aircraft took off, and the early part of the climb appeared normal. Analysis of the eye witness reports, and consideration of their locations and fields of view, led to a deduction that this normal climb continued to a height of between 200 and 300 ft above the ground. The aircraft then appeared to ‘sink’, losing a small amount of height without yawing or rolling, before yawing to the right, then rolling to the right, and pitching nose down into an incipient spin to the right. The surviving passenger recalled that the stall warning sounded, and its accompanying red light (which was mounted on the right-hand side of the instrument panel and in his line of sight) illuminated throughout this period and until impact. Witnesses described that the (incipient) spin continued until the aircraft struck the ground. ATC staff in the visual control room activated the airport’s crash alarm. The rescue and fire-fighting service (RFFS) responded promptly from their station; the crew of one RFFS vehicle, working on the airport, observed the accident and responded directly to it. The pilot and one passenger were fatally injured on impact. Another passenger succumbed to her injuries before she could be extricated from the wreckage, and the third passenger, who had sustained serious injuries, was taken to hospital.
Probable cause:
The investigation identified the following causal factors:
1. Significant rainfall, and anomalies in the aircraft’s fuel filler neck and cap, led to the presence of water in the right-hand fuel tank,
2. Shortly after takeoff, the water in the right-hand fuel tank entered the engine fuel system causing the engine to stop running,
3. Control of the aircraft was not retained after the right-hand engine stopped.
Contributing factors:
1. No pre-flight water drain check was carried out; such a check would have allowed the presence of water in the right-hand fuel tank to be detected and corrective action taken.
2. It is possible that performance-reducing windshear, encountered during the downwind departure, contributed to a reduction in airspeed shortly before the aircraft stalled.
Final Report:

Crash of a Britten-Norman BN-2B-26 Islander near Jhuosi: 3 killed

Date & Time: Aug 30, 2012 at 0915 LT
Type of aircraft:
Registration:
B-68801
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Taipei - Taitung
MSN:
2255
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12545
Captain / Total hours on type:
465.00
Copilot / Total flying hours:
11212
Copilot / Total hours on type:
245
Aircraft flight hours:
4909
Aircraft flight cycles:
2426
Circumstances:
On August 30, 2012, a RAC’s BN-2B-26 aircraft, registration number B-68801, contracted by Real World Engineering Consultants Inc. (Real World) to perform an aerial photogrammetry mission with a captain, a first officer and an aerial photographer on board. The flight plan was to take off from Songshan Airport, requested for instrument departure and visual flight rules to conduct aerial photogrammetry mission in Hualien and Taitung area, the aircraft planned to land at Taitung Airport after the mission accomplished. The aircraft took off at 0726, approximately 18 minutes after took off, the flight crew changed flight mode from instrument flight rules to visual flight rules. At 0827, the aircraft entered Hualien County Fenglin, Guangfu, Wanrong aerial photograph area, maintain 8,300 feet to 8,500 feet altitude and continued climbing to Jhuosi, Hualien County photo area at 0919. From 0837 to 0843, Taipei Approach informed the flight crew ‘Radar can’t cover you…..make sure maintain visual flight’. There were about 7 times communication blockage between the aircraft and Taipei Approach during 0755 to 0913 period. The Kaohsiung Approach Control contacted the aircraft at 0913:39 and lost contact with the aircraft at 0914:20 after the last communication. At 0920:55, the aircraft was at 260 degrees, 31.5 km mountain area from Yuli, Taitung and began to turn right heading 280 degrees. The last recorded Light Detection and Ranging (LIDAR) device data was 262 degrees, 35.9 km west of Yuli′s mountain area with coordinates of 23 ° 20 ′25.01 " latitude and 121 ° 01′ 50.03" longitude. At the time of the last recording, the aircraft was at 9,572 feet with about 69 knots ground speed, 250 degrees heading, the climb rate was 874 ft / min and the pitch was 23.5 degrees. At 0940, Taipei Mission Control Center (MCC) received ELT (Emergency Locator Transmitter) signals, about the same time, Japan Coast Guard informed Rescue Command Center, Executive Yuan (RCC) of the same ELT signals. After verification with Civil Aeronautics Administration, Ministry of Transportation and Communications (CAA), RCC confirmed that the aircraft had lost contact. At 0955 on September 1, 2012, the search and rescue aircraft discovered the aircraft crashed at altitude about 9,568 feet of the original forest, about 20 kilometers southwest of Jhuosi, Hualien County. Three crew members on board were killed, and the aircraft was destroyed.
Probable cause:
After completing the aerial photogrammetry of Morakot No.16 measuring line, the aircraft turned 280 degrees to the right and attempted to climb to get out of the valley area. During climbing, the pitch of the aircraft was remained more than 20 degrees for a few seconds, the aircraft might nearly close to stall and activated stall warning. The aircraft performance might not be able to fly over the obstacles ahead under this condition, the aircraft flew into trees and crashed. When completing the aerial photography of Morakot No.16 measuring line from the north to the south, the aircraft could not be able to fly over mountains ahead between the direction of 9 to 3 o’clock with the aircraft best climb performance. Despite the available climbing distance was longer when flight crew chose to turn to the right, the area geography was not favorable for circling climb or turn around to escape the mountain area safely. The on board personnel choose to perform an aerial photogrammetry at Morakot when weather condition was permitted after completing the aerial photography at Wanrong Woods without any advance planning due to the Morakot aerial photography had been behind schedule.
Final Report:

Crash of a Britten-Norman BN-2T Islander in Dhorpatan: 6 killed

Date & Time: Oct 18, 2011 at 1906 LT
Type of aircraft:
Operator:
Registration:
RAN-49
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nepalgunj – Kathmandou
MSN:
2191
YOM:
1988
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The single engine aircraft was performing an ambulance flight from Nepalgunj to the capital city Kathmandu with a patient, one accompanist, two doctors, a nurse and a pilot on board. It crashed in unknown circumstances in a hilly and wooded terrain near Dhorpatan, killing all six occupants.

Crash of a Britten Norman BN-2A-7 Islander in Port Kaituma

Date & Time: Aug 20, 2011 at 1200 LT
Type of aircraft:
Operator:
Registration:
8R-GHD
Survivors:
Yes
MSN:
622
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the pilot started the descent to Port Kaituma in poor weather conditions (heavy rain falls). After touchdown on a wet runway, the twin engine aircraft skidded, veered off runway, hit a pole with its left wing and lost its nose gear before coming to rest. While all four occupants escaped with minor injuries, the aircraft was damaged beyond repair.

Crash of a Britten-Norman BN-2A Defender near Ouarzazate: 5 killed

Date & Time: Dec 8, 2010
Type of aircraft:
Registration:
CN-TWO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Tangier - Ouarzazate
MSN:
2232
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Tangier on a flight to Ouarzazate, carrying three Police Officers and two pilots on behalf of the Royal Moroccan Police (Gendarmerie Royale Marocaine). While cruising by night between Demnate and Ouarzazate, the aircraft struck a mountain slope and crashed. The wreckage was found two days later in an isolated area. The aircraft was totally destroyed and all five occupants were killed. For unknown reasons, the crew was flying at an insufficient altitude.
Probable cause:
Controlled flight into terrain.

Crash of a Britten-Norman BN-2A-21 Islander in Kodiak

Date & Time: Mar 15, 2010 at 1243 LT
Type of aircraft:
Operator:
Registration:
N663SA
Flight Phase:
Survivors:
Yes
Schedule:
Kodiak - Old Harbor
MSN:
4
YOM:
1967
Flight number:
8D501
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7370
Captain / Total hours on type:
106.00
Aircraft flight hours:
11348
Circumstances:
The airline transport pilot was taking off on a passenger flight under Title 14, CFR Part 135, when the accident occurred. He reported that during takeoff the wind was reported from 290-300 degrees, at 15 knots, gusting to 27 knots. He chose to make an intersection takeoff on runway 25 at its intersection with runway 29, rather than use the full length of runway 29. He said his airspeed did not develop as quickly as he had anticipated, and that with his airspeed lagging and poor climb performance, he realized the airplane was not going to clear the ridge at the end of the runway. He said he initiated a right descending turn to maintain his airspeed, but impacted trees alongside the runway. He reported that the airplane sustained substantial damage to the wings and fuselage when it impacted trees. He said there were no mechanical problems with the airplane prior to the accident.
Probable cause:
The pilot's failure to maintain clearance from rising terrain during takeoff resulting in collision with trees.
Final Report:

Crash of a Britten-Norman BN-2A-8 Islander off Kralendijk: 1 killed

Date & Time: Oct 22, 2009 at 1017 LT
Type of aircraft:
Operator:
Registration:
PJ-SUN
Survivors:
Yes
Schedule:
Willemstad – Kralendijk
MSN:
377
YOM:
1973
Flight number:
DVR014
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1738
Captain / Total hours on type:
565.00
Aircraft flight hours:
16670
Circumstances:
On 22 October the pilot concerned got up at 05.00 and drove towards the airport at about 05.30. After preparing the aircraft, with registration PJ-SUN, he piloted two return flights from Curaçao International Airport (hereinafter to be referred to as Hato airport) to Bonaire International Airport (hereinafter to be referred to as Flamingo airport). No problems occurred during these four flights. The departure for the next flight, “DVR014”, was planned at 09.30. The nine passengers booked for this flight, who had already had their luggage weighed, had to wait before they could board because the pilot had ordered the aircraft to be refuelled prior to this flight. The refuelling invoice of flight DVR014 specifies that fuel was taken up between 09.28 and 09.38. The luggage of these passengers and some additional cargo consisting of a few boxes had already been loaded on to the aircraft. The passengers were welcomed by the pilot when they boarded. The pilot informed them they should keep their waist belts fastened during the flight and that the safety cards were located in the seat pockets. From the passenger statements it can be deduced that these instructions were not heard by all of the passengers. The pilot and the passenger seated next to him fastened their waist and shoulder belts. Approximately ten minutes after the estimated time of departure, after having received the required approval from the Hato Tower air traffic control tower (hereinafter to be referred to as Hato Tower) via the on-board radio the engines were started without any problems. The flight manual engine ground checks were not extensively performed because these are part of the first flight of the day engine checks in accordance with the General Operating Manual. Around 09.47 the PJ-SUN took off for a flight with visual flight rules (VFR) to Bonaire. After take-off the aircraft climbed to flight level 035 (FL035). Some of the passengers had flown for some years, several times in a week with Divi Divi Air. From the passenger statements it can be deduced that the pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. The passenger next to the pilot stated that engine power ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Some passengers reported they felt a jolt that moment. Some passengers reported the engine sputtered shortly before it ceased. No sound from which a mechanical problem was heard and no smoke was detected. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09.52 the pilot reported to the Hato Tower controller: Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines. The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control (hereinafter to be referred to as Flamingo Tower) at 09.57 and reported: 014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18. The Flamingo Tower controller authorized the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did. The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing. According to the statements of a few of the passengers, the aircraft pitch attitude increased during the descent of the aircraft and it was higher than usual. The indicated airspeed on the airspeed indicator was lower than when flying with two working engines. The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water. At 10.08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10.12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorized the landing. At 10.14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10.15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing. There were life jackets for all people on-board. The pilot, the passenger seated next to him and two passengers seated in the back row did not have their life jackets on. The passengers in rows two through to four had put on their life jackets. One passenger had put on his life jacket back to front. According to the statements of the passengers, the stall warning (loud tone) was activated on and off during this last part of the flight. A short time before the emergency landing until the moment of impact with the water the stall warning was continuously audible. From the statements of the passengers it follows the all cabin doors were closed throughout the descent and the landing. The passenger’ statements differ in describing the last part of the flight until the impact of the aircraft with the water surface. One passenger stated that the aircraft fell down from a low height and impacted the water with a blow. Other passengers mentioned a high or low aircraft pitch attitude during impact. Most of the passengers stated that during impact the left wing was slightly down. The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact. The aircraft was lying horizontally in the water. The height of the waves was estimated 0.5 meter by one of the passengers. The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. The passenger behind the pilot was trapped, but was able to free herself from this position. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene. Divers from the first boat tried to localise the sunken aircraft based on indications from the passengers. The people on the other boat took nine passengers out of the water and set course to Kralendijk where they arrived at approximately 10.37. The police and other emergency services personnel were awaiting the passengers on the quay. Six passengers were transported to the hospital where they were discharged after an examination. The other three went their own way.
Probable cause:
The following factors were identified:
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors:
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors:
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (Copi) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organized and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.
Final Report: