Crash of a De Havilland DHC-6 Twin Otter 200 in Palm Beach

Date & Time: Apr 5, 1999 at 0945 LT
Operator:
Registration:
N838MA
Survivors:
Yes
Schedule:
Palm Beach - Kissimmee
MSN:
188
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
200.00
Aircraft flight hours:
16659
Circumstances:
The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. Approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem, shut down the right engine, and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed.
Probable cause:
The pilot's failure to secure the engine oil filler cap during the preflight inspection that resulted the subsequent loss of engine power, and his in-flight decision to attempt a single engine go-around with full wing flaps extended.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Davis Inlet: 1 killed

Date & Time: Mar 19, 1999 at 0945 LT
Operator:
Registration:
C-FWLQ
Flight Type:
Survivors:
Yes
Schedule:
Goose Bay - Davis Inlet
MSN:
724
YOM:
1980
Flight number:
PB960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1600
Captain / Total hours on type:
2500.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
70
Aircraft flight hours:
30490
Circumstances:
The flight was a pilot self-dispatched, non-scheduled cargo flight from Goose Bay to Davis Inlet, Newfoundland, and was operating as Speed Air 960 under a defence visual flight rules flight plan. Before the flight, the captain received weather information from the St. John's, Newfoundland, flight service station (FSS) via telephone and fax. The aircraft departed for Davis Inlet at 0815 Atlantic standard time (AST). The captain was the pilot flying (PF). During the first approach, the first officer (FO) had occasional visual glimpses of the snow on the surface. The captain descended the aircraft to the minimum descent altitude (MDA) of 1340 feet above sea level (asl). When the crew did not acquire the required visual references at the missed approach point, they executed a missed approach. On the second approach, the captain flew outbound from the beacon at 3000 feet asl until turning on the inbound track. It was decided that if visual contact of the surface was made at any time during the approach procedure, they would continue below the MDA in anticipation of the required visual references. The captain initiated a constant descent at approximately 1500 feet per minute with 10 degrees flap selected. The FO occasionally caught glimpses of the surface. At MDA, in whiteout conditions, the captain continued the descent. In the final stages of the descent, the FO acquired visual ground contact; 16 seconds before impact, the captain also acquired visual ground contact. At 8 seconds before impact, the crew selected maximum propeller revolutions per minute. The aircraft struck the ice in controlled flight two nautical miles (nm) from the airport (see Appendix B). During both approaches, the aircraft encountered airframe icing. The crew selected wing de-ice, which functioned normally by removing the ice.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The captain decided to descend below the minimum descent altitude (MDA) without the required visual references.
2. After descending below MDA, both pilots were preoccupied with acquiring and maintaining visual contact with the ground and did not adequately monitor the flight instruments; thus, the aircraft flew into the ice.
Findings as to Risk:
1. The flight crew did not follow company standard operating procedures.
2. Portions of the flight were conducted in areas where the minimum visual meteorological conditions required for visual flight rules flight were not present.
3. Although both pilots recently attended crew resource management (CRM) training, important CRM concepts were not applied during the flight.
4. The cargo was not adequately secured before departure, which increased the risk of injury to the crew.
5. The company manager and the pilot-in-command did not ensure that safe aircraft loading procedures were followed for the occurrence flight.
6. There were lapses in the company's management of the Goose Bay operation; these lapses were not detected by Transport Canada's safety oversight activities.
7. The aircraft was not equipped with a ground proximity warning system, nor was one required by regulation.
8. Records establish that the aircraft departed approximately 500 pounds overweight.
Other Findings:
1. The flight crew were certified, trained, and qualified to operate the flight in accordance with existing regulations and had recently attended CRM training.
2. During both instrument approaches, the aircraft was operating in instrument meteorological conditions and icing conditions.
3. There was no airframe failure or system malfunction prior to or during the flight. In particular, the airframe de-icing system was serviceable and in operation during both approaches.
4. It was determined that an ice-contaminated tailplane stall did not occur.
5. The fuel weight was not properly recorded in the journey logbook.
6. The wreckage pattern was consistent with a controlled, shallow descent.
7. The emergency locator transmitter was damaged due to impact forces during the accident, rendering it inoperable.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Praia: 1 killed

Date & Time: Sep 28, 1998 at 1330 LT
Operator:
Registration:
D4-CAX
Flight Type:
Survivors:
Yes
Schedule:
Campo de Priguiça – Praia
MSN:
550
YOM:
1977
Flight number:
VR5301
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The twin engine aircraft was completing a government flight (VR5301) from Campo de Priguiça to Praia, carrying three crew members and the Prime Minister Carlos Veiga and his team. On approach to Praia-Francisco Mendes Airport, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong winds. The crew was cleared to make a low pass over runway 22 then make a sharp turn to the left, causing the left wing tip to struck the ground. Out of control, the aircraft crashed 150 metres from the runway 04 threshold. A passenger, a Prime Minister's bodyguard, was killed while 21 other occupants were injured, four seriously.
Probable cause:
It was reported that prior to departure from Campo de Priguiça Airport, the crew was informed about weather conditions at destination that were considered as good with 10 km visibility and clouds at 1,400 feet. It was determined that weather conditions at Praia Airport deteriorated en route and the crew failed to obtain a second bulletin from ATC based at Praia. Also, the crew departed Campo de Priguiça Airport with insufficient fuel reserve, which contributed to the precipitation of the last flight sequence.

Crash of a De Havilland DHC-6 Twin Otter near Ghorepani: 18 killed

Date & Time: Aug 21, 1998 at 1124 LT
Registration:
9N-ACC
Flight Phase:
Survivors:
No
Site:
Schedule:
Jomsom - Pokhara
MSN:
710
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine aircraft departed Jomsom Airport at 1110LT on a 20-minutes flight to Pokhara, carrying 15 passengers and three crew members. While cruising at an altitude of 10,500 feet in good weather conditions, the aircraft struck the slope of a mountain. The wreckage was found two days later and all 18 occupants were killed.

Crash of a De Havilland DHC-6 Twin Otter 100 in Antofagasta

Date & Time: Aug 19, 1998
Operator:
Registration:
935
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Antofagasta - Antofagasta
MSN:
7
YOM:
1966
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Antofagasta-Cerro Moreno Airport (Andrés Sabella Gálvez Intl Airport). At liftoff, the pilot-in-command initiated a sharp turn to the right, causing the left wing tip to struck the ground. Out of control, the aircraft crashed by the runway. All three occupants were injured and the aircraft was damaged beyond repair. It was reported that the pilot-in-command was a Mirage fighter jet captain. When ATC requested the crew to expedite the takeoff, the pilot-in-command made a sharp turn at low height, apparently not aware about the aircraft wingspan.

Crash of a De Havilland DHC-6 Twin Otter 310 in Limbang

Date & Time: Jan 8, 1998 at 1744 LT
Operator:
Registration:
9M-MDJ
Survivors:
Yes
Schedule:
Miri - Limbang
MSN:
791
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft landed a little too far down the runway and bounced twice. Out of control, it skidded and overran the runway before coming to rest in a ditch. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 near Simbai

Date & Time: Nov 9, 1997 at 1000 LT
Operator:
Registration:
VH-HPY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Koinambe - Simbai
MSN:
706
YOM:
1980
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2206
Captain / Total hours on type:
576.00
Copilot / Total flying hours:
2460
Copilot / Total hours on type:
900
Aircraft flight hours:
18096
Circumstances:
The flight was one of a series being conducted by No. 173 Surveillance Squadron, 1st Aviation Regiment operating a de Havilland Canada DHC-6 (Twin Otter) aircraft as Exercise Highland Pursuit 2/97. The purpose of the exercise was to provide training for three No. 173 Squadron pilots in tropical mountainous operations in Papua New Guinea (PNG). All trainees were qualified on the aircraft type. The training pilot was the pilot in command. He had extensive experience in flying Twin Otter and other aircraft types in PNG as a civilian pilot and had also flown de Havilland Canada DHC-4 (Caribou) aircraft in PNG as a military pilot. Passengers were not carried on the flight. The plan for 9 November 1997 was to fly from Madang and return via a number of airstrips where landing and take-off exercises would be conducted. A flight plan was submitted to Madang Flight Service. At 0915 PNG time, the aircraft arrived at Koinambe where each trainee conducted landing and take-off practice. During this time, the training pilot occupied the right cockpit seat while the trainees, in turn, flew the aircraft from the left cockpit seat. The crew had flight-planned to track direct from Koinambe to Simbai. However, before departing Koinambe, they assessed that this would not be possible because of haze and cloud on track. The training pilot, who was still occupying the right control position, suggested that they could follow the Jimi River north-west from Koinambe and then one of its tributaries towards Simbai. This involved a right turn off the Jimi River about 37 km from Koinambe to follow the valley that passed about 2 km south of Dusin airstrip and then tracked south-east towards Simbai. The navigating pilot, in the left cockpit seat, suggested that, instead of following the tributary off the Jimi River as suggested by the training pilot, they should follow the valley which extended north-east off the Jimi River from a position about 17 km north-west of Koinambe. This was a shorter route than that suggested by the training pilot. The training pilot agreed that the route could be attempted. Neither during this discussion, nor at any earlier time, was there any reference to the elevation of the Bismarck Range. (The increase in ground elevation from the Jimi River to the Bismarck Range, a straight-line distance of about 17 km, is approximately 7,400 ft.) The crew was using an Operational Navigation Chart (ONC) 1:1,000,000-scale chart for in-flight navigation. After departing Koinambe, the crew began following the Jimi River, flying at about 1,000 ft above ground level (AGL). The training pilot had intended to remain in the right cockpit seat for the short flight to Simbai. However, to gain the maximum benefit from flying time during the exercise, he had adopted the practice of having trainees occupy both cockpit seats during the en-route sectors of the exercise. He would then monitor the progress of the flight from either between the cockpit seats or the aircraft cabin. In this instance, he vacated the right seat for a trainee who then became the flying pilot for the sector. The navigating pilot then made the required radio calls, one on VHF radio and the other (which was unsuccessful at the first attempt) on HF radio to Madang Flight Service to report the departure of the aircraft from Koinambe. A short time later, the navigating pilot became unsure of the aircraft's position. The flying pilot then conducted several left orbits while the navigating pilot obtained a Global Positioning System (GPS) fix and plotted the position on the ONC chart. He indicated on the chart, and received agreement from the training pilot, that he had identified the aircraft's position. The flying pilot then resumed tracking along the river. During this time the training pilot was in the cabin of the aircraft. He was wearing a headset which was equipped with an extension lead to enable him to communicate with the cockpit crew. He was frequently checking the aircraft's position through the cabin side windows. A short time later, the navigating pilot indicated what he believed to be the valley where the aircraft was to turn towards Simbai. The flying pilot turned the aircraft into this valley. He estimated that the aircraft was flying about 500 ft above the treetops at this time. The crew did not conduct a heading check to confirm that they were in the correct valley. When the aircraft was well into the valley, the training pilot heard over the intercom the flying and navigating pilots discussing the progress of the flight. He sensed some unease in their voices and moved forward from the aircraft cabin to a position between the cockpit seats. He immediately realised that the aircraft was at an excessive nose-high pitch angle and in a position from where it could not outclimb the terrain ahead or turn and fly out of the valley. The flying and navigating pilots ensured that the engine and propeller controls were set to full power and maximum RPM and selected 10 degrees flap. However, the training pilot assessed that impact with the trees was imminent. He ensured that the trainee seated in the cabin was strapped into his seat and then positioned himself on the floor aft of, and against, the cabin bulkhead. The stall warning activated at that time and, almost immediately, the aircraft crashed through the trees to the ground. When the crew had not reported to flight service by 1004, communication checks were initiated. An uncertainty phase was declared at 1023 when there was no contact with the crew. At 1045, this was upgraded to a distress phase after the pilot of a helicopter operating in the area reported that the aircraft was not on the ground at Simbai airstrip. The pilot of the helicopter was tasked with tracking from Simbai to Koinambe in an attempt to locate the aircraft. At 1127, the helicopter pilot reported receiving a strong emergency locator transmitter signal and, shortly after, located the accident site in a valley about 9 km south of Simbai.
Probable cause:
The following factors were identified:
1. There had been a significant loss of corporate knowledge, experience and risk appreciation within the Army concerning the operation of Twin Otter type aircraft in tropical mountainous areas.
2. No training needs analysis for the exercise had been conducted.
3. The tasking and briefing of the training pilot were incomplete.
4 The training pilot did not adequately assess the skill development needs of the trainees.
5. The supervision of the flight by the training pilot was inadequate.
6. The scale of chart used by the crew was not appropriate for the route they intended to fly.
Final Report: