Embraer EMB-110 Bandeirante

After passengers were dropped at Curitiba-Afonso Pena Airport, the crew was returning to his base in Jundiaí. Shortly after takeoff from runway 11 by night and marginal weather conditions, the airplane entered clouds at an altitude of 300 feet and continued to climb. Following a left turn, the aircraft climbed to an altitude of 700 feet then entered a right turn and an uncontrolled descent until it crashed in a field located near the Guatupê Police Academy located 3 km northeast of the airport. The accident occurred two minutes after takeoff. The aircraft was totally destroyed and both pilots were killed. At the time of the accident, the visibility was poor due to the night and a cloud base at 300 feet.

The aircraft was refueled with 640 litres (L) of Jet-A1 (AVTUR) in preparation for an early morning departure to Hoskins, New Britain, on 30 March. On 30 March, the crew lodged a flight plan, which stated that the total fuel on board was 2,100 pounds (lbs) (1,208 L). The first sector of the planned route was from Port Moresby to Hoskins. The pilot-in-command (PIC) obtained an area forecast for the flight, which indicated that there were areas of rain and scattered cloud from 1500-5000 feet (ft), with deteriorating conditions forecast for the period between 0400-0800 hours (hrs); for their arrival at Hoskins. The forecast required 30 minutes holding fuel in addition to the flight and statutory fuel requirements. These conditions were normal for their destination at this time of the year.The aircraft departed Port Moresby at 0402, as flight number ND304 for Hoskins. It initially climbed to the planned Flight Level (FL) 140 (14,000 ft), which was 300 ft above the lowest safe altitude (LSA) on the initial RNC track between Port Moresby and Girua, an Instrument Flight Rules (IFR) reporting point on the north coast of the PNG mainland. The LSA for the sector between Girua and the en-route reporting point Maran was 3,300 ft, and the PIC had planned to cruise at 9,000 ft. The sector between Maran and Hoskins was planned at 9,000 ft, with a LSA of 8,300 ft. The purpose of the flight was to transport newspapers and general freight to Hoskins and Rabaul. Flight Information Area (FIA) communications with Nadzab Flight Service used High Frequency (HF) radio, and a Very High Frequency (127.1 MHz) repeater transceiver located near the township of Popondetta. This service was usually monitored by Nadzab Flight Service during their normal hours of operation, for aircraft operating on the Girua to Hoskins track. One of the functions of the Nadzab Flight Service Unit was to record all transmissions received via the Girua repeater site. The crew made a position report, intercepted by Port Moresby Flight Service, advising that they were overhead Maran at 0506, cruising at FL 110 (11,000 ft), and gave an estimated time of arrival (ETA) Hoskins at 0540. That was 2,000 ft higher than the planned level. The position report was received by Port Moresby Flight Service, because Nadzab Flight Service had not commenced operations. It subsequently commenced operations for the day at 0540. Because Nadzab was responsible for the airspace in which ALU was operating, Port Moresby Flight Service advised Nadzab of ALU’s position report, once Nadzab opened. The Maran position report was the last recorded radio contact with the aircraft. No transmission declaring the intention to descend below FL110 was heard from the crew of ALU. No MAYDAY transmission was reported by ATS or other aircrew. When the crew of ALU failed to report their arrival at Hoskins, a search was commenced of the Hoskins aerodrome. At 0650 a DISTRESFA Search and Rescue Phase (SAR) was declared indicating the degree of apprehension held for the safety of the aircraft and its occupants. Later that morning verbal reports were received from a coastal logging company in an area east of Kandrian, that an aircraft had crashed. The wreckage of ALU was found 27 km east of Kandrian, at an elevation of 780 ft above sea level. Both crew members had not survived the impact. The wreckage was located at position 06° 11′ 39.8′′ S, 149° 52′ 58.9′′ E, and was dispersed along a 500 m wreckage trail after colliding with numerous trees and impacting the terrain. The investigation estimated the time of the accident to be about 0523.

The airport's instrument approach procedures included a very high frequency, omnidirectional range (VOR) approach, and a global positioning system (GPS) approach that was not an overlay. The VOR approach procedure included an inbound course to the VOR, and after passage, a descent along the same course to a missed approach point. The missed approach point was defined as 6 nautical miles beyond the VOR, as well as by timing. The pilot twice attempted the VOR approach in instrument meteorological conditions. He flew the first approach to the missed approach point, initiated a missed approach, contacted the controller, and requested a second VOR approach. He then received vectors to rejoin the approach course inbound to the VOR. The airplane subsequently passed over the VOR, on course, about 100 feet above the minimum altitude. However, instead of descending as described in the procedure, the airplane maintained that altitude until reaching the airport, then began a descent. The airplane continued to travel outbound along the same approach course until it impacted rising terrain about 6.5 miles beyond the airport. There was no dedicated distance measuring equipment (DME) onboard the airplane. Instead, distance was determined by the use of an instrument flight rules (IFR)-approved GPS unit. Due to the non-storage capability of the unit, historical waypoint selection could not be determined. The pilot could have selected the airport as a "direct to" waypoint, or, if he had entered flight plan waypoints, the unit would have sequenced from the VOR to the airport during the first approach. In either case, unless the pilot reprogrammed the unit, the last waypoint entered would have remained at the airport, rather than the VOR. The pilot then most likely mistook the airport position for the VOR position, and displaced the beginning of the descent by 6 nautical miles. Also noted, was that once the airplane passed over the VOR en route to the airport, the HSI would have indicated a change of "to" to "from". There were no medical anomalies noted with the pilot and no mechanical anomalies noted with the airplane.

The pilot had flown the airplane the day before the accident and after landing on the morning of the accident; she ordered fuel for the airplane. While exiting the airplane another pilot informed her that he had heard a "popping noise" coming from one of the engines. The pilot of the accident airplane elected to taxi to a run up area to conduct an engine run up. The fuel truck arrived at the run up area and the pilot elected not to refuel the airplane at that time and continued the run up. No anomalies were noted during the run up and the airplane was taxied back to the ramp and parked. The pilot arrived back at the airport later on the day of the accident and did not re-order fuel for the airplane nor did she recall checking the fuel tanks during the preflight inspection of the airplane. The pilot departed and was in cruise flight when she noticed the fuel light on the annunciator panel flickering. The pilot checked the fuel gauges and observed less than 100 pounds of fuel per-side indicated. The pilot declared low fuel with Columbia Approach Control controllers and requested to divert to the nearest airport, Orangeburg Municipal. The controller cleared the pilot for a visual approach to the airport and as she turned the airplane for final, the left engine lost power followed by the right engine. The pilot made a forced landing into the trees about 1/4 mile from the approach end of runway 36. The pilot exited the airplane and telephoned 911 emergency operators on her cell phone. The pilot stated she did not experience any mechanical problems with the airplane before the accident. Examination of the airplane by an FAA inspector revealed the fuel tanks were not ruptured and no fuel was present in the fuel tanks.

According to the pilot, the airplane took off with a flaps setting of 25 percent, per the operator’s procedures at the time. He stated that, immediately after raising the landing gear after takeoff, he heard an explosion and saw that all gauges for the left engine, a Pratt & Whitney Canada (P&WC) PT6A-34, pointed to zero, indicating a loss of power to the left engine. He also noted that the left propeller had completely stopped so he added full power to the right engine, left the flaps at 25 percent, and left the landing gear up. He further stated that, although he “stood on the right rudder,” he could not stop the airplane’s left turning descent. The pilot later noted that, after the left engine lost power, he “couldn’t hold V speeds” and “the stall warning horn was going off the whole time.” Post accident examination of the accident airplane’s left engine revealed that that it had failed and that the propeller had been feathered. Examination of the trim positions revealed that the rudder was at neutral trim and the aileron was at full left trim. Although these trim positions could have been altered when the wings separated from the fuselage during ground impact, the pilot’s comment that he “stood on the rudder” suggests that he either had not trimmed the airplane after the engine failure or had applied trim opposite the desired direction. The activation of the stall warning horn and the pilot’s statement that he “couldn’t hold V speeds” indicate that he also did not lower the nose sufficiently to maintain best single-engine rate of climb or best single-engine angle of climb airspeed. In addition, a performance calculation conducted during the National Transportation Safety Board’s investigation revealed that the airplane, with flaps set at 25 degrees, would have been able to climb at more than 400 feet per minute if the pilot had maintained best single-engine rate of climb airspeed and if the airplane had been properly trimmed. Post accident examination of the accident airplane’s left engine revealed fatigue fracturing of the first-stage sun gear.[1] According to the airplane’s maintenance records, during an October 1998 engine overhaul, the first-stage planet gear assembly was replaced due to “frosted and pitted gear teeth.” The planet gear assembly’s mating sun gear was also examined during overhaul but was found to be serviceable and was reinstalled with the new planet gear assembly, which was an accepted practice at the time. However, since then, the engine manufacturer determined that if either the sun gear or planet gear assembly needed to be replaced with a zero-time component, the corresponding mating gear/assembly must also be replaced with a zero-time component; otherwise, the different wear patterns on the gears could potentially cause “distress” to one or both of the components. Review of maintenance records showed that the engines were maintained, in part, under a Federal Aviation Administration (FAA)-approved “on-condition” maintenance program;[2] Business Air’s maintenance program was approved in May 1995. In April 2002, P&WC, the engine manufacturer, issued Service Bulletin (SB) 1403 Revision 7, which no longer mentioned on-condition maintenance programs and required, for the first time for other time between overhaul extension options, the replacement of a number of PT6A-34, -35, and -36 life-limited engine components, including the first-stage sun gear at 12,000 hours total time since new. The first-stage sun gear on the accident airplane failed at 22,064.8 hours. In November 2005 (when the Manchester accident occurred), Business Air was operating under an engine on-condition maintenance program that did not incorporate the up-to-date PT6A 34, -35, and -36 reliability standards for the life-limited parts listed in SB 1403R7 because the SB did not address previously approved on-condition maintenance programs. Three months later, in an e-mail message to Business Air, P&WC stated that it would continue to “endorse” Business Air’s engine on-condition maintenance program. Although SB 1403R7 improves PT6A-34, -35, and -36 engine reliability standards, allowing grandfathered on condition maintenance programs for these engines is less restrictive and does not offer the same level of reliability. The National Transportation Safety Board’s review of maintenance records further revealed numerous deficiencies in Business Air’s on-condition engine maintenance program that appear to have gone undetected by the Portland, Maine, Flight Standards District Office (FSDO), which is in charge of monitoring Business Air’s operations. For example, one infraction was that Business Air did not specify which parts were included in its on-condition maintenance program and which would have been removed by other means, such as hard-time scheduling.[3] Also, the operator used engine condition trend monitoring as part of determining engine health; however, review of records revealed missing data, inaccurate data input, a lack of regular trend analyses, and a failure to update trends or reestablish baselines when certain maintenance was performed. Another example showed that, although Business Air had an engine-oil analysis program in place, the time it took to send samples for testing and receive results was lengthy. According to maintenance records, the operator took an oil sample from the accident engine more than 2 weeks before the accident and sent it for testing. The oil sample, which revealed increased iron levels, would have provided valuable information about the engine’s health. However, the results, which indicated a decline in engine health, were not received until days after the accident. If the FAA had been properly monitoring Business Air’s maintenance program, it may have been aware of the operator’s inadequate maintenance practices that allowed, among other things, an engine with a sun gear well beyond what the manufacturer considered to be a reliable operating timeframe to continue operation. It also took more than 2 1/2 years after the accident for the FAA to finally present a consent order[4] to the operator, in which both parties not only acknowledged the operator’s ongoing maintenance inadequacies but also the required corrective actions. [1] A sun gear is the center gear around which an engine’s planet gear assembly revolves; together, the sun gear and planet gear assembly provide a means of reducing the engine’s rpm to the propeller’s rpm. [2] According to FAA Advisory Circular (AC) 120-17A, “Maintenance Control by Reliability Methods,” under on-condition maintenance programs, components are required to be periodically inspected or checked against some appropriate physical standard to determine whether they can continue in service. [3] According to FAA AC 120-17A, “Maintenance Control by Reliability Methods,” under hard time maintenance programs, components are required to be periodically overhauled or be removed from service. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders. [4] A consent order is a voluntary agreement worked out between two or more parties to a dispute. It generally has the same effect as a court order and can be enforced by the court if anyone does not comply with the orders.

En route to the company's home airport, the twin-engine airplane either experienced a loss of power to the right engine, or the pilot decided to shut the engine down. Although the home airport had night visual meteorological conditions, and there was no evidence of any malfunction with the remaining engine, the pilot opted to fly a night precision instrument approach to an airport 45 nautical miles closer, with a 1-mile visibility and a 100-foot ceiling. Unknown to the pilot, there was also fog at the airport. The pilot did not advise or seek assistance from air traffic control or the company. When the airplane broke out of the clouds, it was not stable. Approaching the runway, at full flaps and exceeding the 25 percent maximum for a go-around, the pilot added full power to the left engine. The high power setting, slow airspeed, and full flaps combination resulted in a minimum control speed (Vmc) roll. No determination could be made as to why the right engine was inoperative, and there were no mechanical or fuel-related anomalies found that would have precluded normal operation.

When the crew departed São Paulo-Guarulhos Airport, weather conditions at destination were considered as good. These conditions deteriorated en route and when the crew started the approach to Uberaba Airport by night, the visibility was below IFR minimums. Nevertheless, the crew attempted to land, continued the approach, descended below the MDA by 240 feet when the aircraft struck two houses and crashed in the district of Conjunto Pontal, bursting into flames. The wreckage was found about 800 metres short of runway 17 threshold. Both pilots as well as one people in a house were killed.

During the takeoff roll, the left engine failed. Control was lost and the aircraft veered off runway and came to rest. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

The aircraft was performing a flight from Freetown-Lungi Airport to Freetown-Hastings located southeast of the capital city. During the night, rebels sabotaged the runway with concrete and steel projectiles. After landing, the right main gear struck several obstructions and was torn off. The aircraft came to rest and was damaged beyond repair while all 16 occupants escaped uninjured. The exact date of the mishap remains unknown, somewhere in 2002.

On final approach to Havana-José Marti-Rancho Boyeros Airport by night, the crew encountered poor weather conditions with heavy rain falls. In limited visibility, the aircraft descended too low when it impacted the ground and crashed in a wasteland located less than one km from the runway threshold. All 10 occupants were injured and the aircraft was destroyed.