Country
Crash of a Piper PA-31-350 Navajo Chieftain off Nahant
Date & Time:
May 5, 2001 at 2015 LT
Registration:
N3558G
Survivors:
Yes
Schedule:
Nantucket – Beverly
MSN:
31-8052068
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
65.00
Aircraft flight hours:
3000
Circumstances:
The pilot departed his home airport for a 90 mile personal flight with eight passengers. The pilot stated he departed with 24 gallons of fuel in the outboard tanks, and 80 gallons of fuel in the main tanks. After landing, the airplane was refueled with 100 low-lead aviation gasoline; 12 gallons in each main fuel tank. Before departing for the return flight, the pilot performed a preflight inspection of the airplane, which did not include a visual check of the airplane's fuel tanks. After takeoff, the pilot experienced a "small surge in both engines," while climbing through 1,150 and 3,300 feet, respectively. He further described the surges as "minor but still noticeable." About 30 minutes later, after the airplane had descended, and was leveling at 1,500 feet, the pilot experienced an intermittent illumination of the "right aux fuel pump light," which was followed by a total loss of power on the right engine. Shortly thereafter, the left engine began "surging," and after about "three or four minutes, at most," he feathered the left engine propeller. The pilot ditched the airplane in Massachusetts Bay. The airplane was recovered about 1 month later. The fuel selectors were positioned to the outboard tanks, and the airplane's fuel tanks revealed fluid consistent with seawater with "some odor of fuel;" however, no visible evidence of fuel was observed. According to the airplane's information manual, the airplane's total fuel capacity was 192 gallons, of which, 182 gallons were usable. Examination of the airframe and engine did not reveal evidence of any pre-impact mechanical malfunctions. The pilot reported he had purchased the airplane and attended 5-day type specific training course in March 2001. He reported about 1,050 hours of total fight experience, which included 800 hours in multi-engine airplanes, of which 65 hours was in the make and model. Additionally, the pilot reported he had not experienced any prior mechanical problems. He believed he had flown the airplane the day prior to the accident as well. The last documented refueling of the airplane prior to the date of the accident occurred on May 3, 2001, when the airplane was refueled with 128 gallons of aviation gasoline. The last flight documented in the pilot's logbook was on May 4, 2001, when the pilot logged 1.9 hours in the accident airplane. The pilot said he normally flew a 65 percent power, an "a little rich," and experienced a fuel burn of about 20 to 21 gallons per hour, for each engine.
Probable cause:
A loss of engine power due to fuel exhaustion for undetermined reasons. A factor in this accident was the pilot's failure to visual check the airplane's fuel quantity prior to takeoff.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain in Orléans
Date & Time:
Mar 22, 2001 at 1835 LT
Registration:
PH-ABD
Survivors:
Yes
Schedule:
Orléans - Paris
MSN:
31-7305048
YOM:
1973
Flight number:
TLP2B
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
688.00
Copilot / Total hours on type:
50
Aircraft flight hours:
9820
Circumstances:
On 22 March 2001 at about 17h35, the PA-31-350 Chieftain registered PH-ABD, call sign Tulip 2B, began its takeoff from runway 23 at Orléans-Saint Denis de l’Hôtel for an IFR departure to Paris-Le Bourget. The flight was passenger charter flight TLP2B. The pilot flying, who was the co-pilot seated in the left seat, was unable to perform the rotation. He aborted the takeoff but braking failed to stop the aircraft before the end of the runway. The runway surface was wet. Marks were left by the tyres from one hundred metres before the end of the runway. The aircraft ran across grass soaked with water. The nose gear broke and the aircraft came to a stop about one hundred and eighty metres after the end of the runway. The crew had forgotten to remove the flight control locking device.
Probable cause:
The accident was caused by the crew’s failure to perform pre-flight actions and checks relating to unblocking and free movement of the flight controls and flight control surfaces. This failure was able to develop to the point of being the cause of the accident as a result of the absence of precise CRM procedures.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain in Val d'Or
Date & Time:
Feb 20, 2001 at 1900 LT
Registration:
C-GNIE
Survivors:
Yes
Schedule:
Rouyn – Val d’Or – Saint-Hubert
MSN:
31-7552047
YOM:
1975
Flight number:
APO1023
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
30.00
Circumstances:
A Piper PA-31-350, registration C-GNIE, serial number 31-7552047, was on a scheduled (APO1023) instrument flight rules mail service flight between Rouyn Airport, Quebec, and Val-d'Or Airport, Quebec, at approximately 1845 . After checking for prevailing weather conditions at the destination airport, the pilot decided to make a visual approach on runway 36. The pilot reported by radio at two miles on final approach for runway 36 and then stated that he was going to begin his approach again after momentarily losing visual contact with the runway. This was the last radio contact with the aircraft. No emergency locator transmitter signal was received by the flight service station specialist. Emergency procedures were initiated, and searches were conducted. The aircraft was found by a search and rescue team about three hours after the crash. The aircraft was lying about two miles southeast of the end of runway 36; it was substantially damaged. The pilot suffered serious injuries.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The environmental conditions and loss of visual ground references near Val-d'Or Airport were conducive to spatial disorientation. Because of a lack of instrument flight experience, the pilot probably became disoriented during the overshoot and was unable to regain control of the situation.
2. During the approach, the pilot did not plan to and did not pull up towards the centre of the airport, thereby contributing to spatial disorientation.
3. Although the pilot-in-command received training required by Transport Canada, Aéropro did not ensure that the pilot-in-command completed the required Pilot Proficiency Check (PPC) and was adequately supervised and experienced to conduct a night IFR flight safely as pilot-in-command.
1. The environmental conditions and loss of visual ground references near Val-d'Or Airport were conducive to spatial disorientation. Because of a lack of instrument flight experience, the pilot probably became disoriented during the overshoot and was unable to regain control of the situation.
2. During the approach, the pilot did not plan to and did not pull up towards the centre of the airport, thereby contributing to spatial disorientation.
3. Although the pilot-in-command received training required by Transport Canada, Aéropro did not ensure that the pilot-in-command completed the required Pilot Proficiency Check (PPC) and was adequately supervised and experienced to conduct a night IFR flight safely as pilot-in-command.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain off Hilo: 1 killed
Date & Time:
Aug 25, 2000 at 1735 LT
Registration:
N923BA
Survivors:
Yes
Schedule:
Kona – Kona
MSN:
31-8252024
YOM:
1982
Flight number:
BIA057
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total hours on type:
465.00
Aircraft flight hours:
3492
Circumstances:
The pilot ditched the twin engine airplane in the Pacific ocean after experiencing a loss of engine power and an in-flight engine fire while in cruise flight. The flight was operating at 1,000 feet msl, when the pilot noticed a loss of engine power in the right engine. At the same time the pilot was noticing the power loss, passengers noted a fire coming from the right engine cowling. The pilot secured the right engine and feathered the propeller. He attempted to land the airplane at a nearby airport; however, when he realized that the airplane was unable to maintain altitude he elected to ditch the airplane in the ocean. Prior to executing the forced landing, the pilot instructed the passengers to don their life jackets and assume the crash position. After touchdown, all but one passenger exited the airplane through the main cabin and pilot doors. It was reported that the remaining passenger was frightened, and could not swim. One survivor saw the remaining passenger sitting in the seat with the seat belt still secured and the life vest inflated. The pilot and passengers were then rescued from the ocean via rescue helicopter and boat. Postaccident examination of the airplane revealed that the right engine's oil converter plate gasket had deteriorated and extruded from behind the converter plate, allowing oil to spray in the accessory section and resulting in the subsequent engine fire. The engine manufacturer had previously issued a mandatory service bulletin (MSB) requiring inspection of the gasket every 50 hours for evidence of gasket extrusion around the cover plate or oil leakage. Maintenance records revealed that the inspection had been conducted 18.3 hours prior to the accident. At the time of the accident, the right engine had accumulated 386.8 hours since its last overhaul, and gasket replacement. The MSB was issued one month prior to the accident, after the manufacturer received reports of certain oil filter converter plate gaskets extruding around the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak and spray from between the plate and the accessory housing. A series of tests were conducted on exemplar gaskets by submerging them in engine oil heated to 245 degrees F; after about 290 hours, the gasket material displayed signs of deterioration similar to that of the accident gasket. A subsequent investigation revealed that the engine manufacturer had recently changed gasket suppliers, which resulted in a shipment of gaskets getting into the supply chain that did not meet specifications. As a result of this accident, the engine manufacturer revised the MSB to require the replacement of the gasket every 50 hours. The FAA followed suit and issued an airworthiness directive to mandate the replacement of the gasket every 50 hours.
Probable cause:
Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain in Hazlehurst: 3 killed
Date & Time:
Aug 15, 2000 at 0825 LT
Registration:
N801MW
Survivors:
No
Schedule:
Dothan - Hazlehurst
MSN:
31-8152136
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The flight was cleared for an NDB or GPS runway 14 instrument approach. The pilot was instructed to report procedure turn. Center radar reported the airplane's altitude was last observed at 200 feet. A witness observed the airplane as it collided with trees and the ground and, subsequently burst into flames. No mechanical problem with the airplane was reported by the pilot or discovered during the wreckage examination. Weather minimums for the approach are 800 feet an one mile. Low clouds were reported in the area at the time of the accident.
Probable cause:
Pilot's failure to follow instrument procedures and descended below approach minimums and collided with trees. A factor was low clouds.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain in Burlington: 9 killed
Date & Time:
Aug 9, 2000 at 0752 LT
Registration:
N27944
Survivors:
No
Schedule:
Lakehurst - Patuxent
MSN:
31-7952056
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total hours on type:
1418.00
Circumstances:
A Piper PA-31-350 Navajo Chieftain, N27944, operated by Patuxent Airways, Inc., Hollywood, Maryland, and a Piper PA-44-180 Seminole, N2225G, operated by Hortman Aviation Services, Inc., Philadelphia, Pennsylvania, were destroyed when they collided in flight over Burlington Township, New Jersey. The airline transport pilot, commercial pilot, and seven passengers aboard the Navajo Chieftain were killed, as were the flight instructor and the private pilot aboard the Seminole. Day visual meteorological conditions existed at the time of the accident, and both airplanes were operating under visual flight rules when the collision occurred. The flight crews of both airplanes were properly certificated and qualified in accordance with applicable Federal regulations. None of these individuals was experiencing any personal problems or rest anomalies that would have affected their performance. The airplanes had undergone the required inspections. Examination of their maintenance documents revealed that both airplanes complied with all appropriate airworthiness directives. Evidence gathered from the wreckage indicated that neither airplane had experienced an in-flight fire, bird strike, or structural or mechanical failure. Tissue samples revealed that the pilot of the Seminole had taken doxylamine sometime before the accident. (Doxylamine is a sedating antihistamine that has substantial adverse effects on performance.) However, the amount of blood available for analysis was insufficient for determining exactly when the pilot may have ingested the medication or whether his performance was impaired by the effects of doxylamine. A partial cockpit visibility study revealed that the Seminole would have been visible to the pilots in the Chieftain for at least the 60 seconds before the collision. No stereo photographs from a Seminole cockpit were available to determine precise obstruction angles. However, because of the relative viewing angle, the Chieftain would have been visible to the pilots in the Seminole for most of the last 60 seconds. The study further revealed that about 4 seconds before impact, or about .11 nm separation, the angular width of each airplane in each pilot's field of vision would have been approximately 0.5 to 0.6 degrees or about 1/4 inch apparent size at the windscreen.
Probable cause:
The failure of the pilots of the two airplanes to see and avoid each other and maintain proper airspace separation during visual flight rules flight.
Final Report:
Crash of a Piper PA-31-350 Navajo Chieftain off Liverpool: 5 killed
Date & Time:
Jun 14, 2000 at 0950 LT
Registration:
G-BMBC
Survivors:
No
Schedule:
Douglas - Liverpool
MSN:
31-7952172
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The aircraft, operated by an Air Operator's Certificate holder, was engaged on an air ambulance operation from Ronaldsway in the Isle of Man to Liverpool. Having flown under VFR on a direct track to the Seaforth dock area of Liverpool the pilot flew by visual reference along the northern coast of the Mersey Estuary to carry out a visual approach to Runway 09 at Liverpool. During the turn on to the final approach, when approximately 0.8 nm from the threshold and 0.38 nm south of the extended centreline, the aircraft flew into the sea and disappeared. All five occupants were killed.
Probable cause:
The investigation concluded that the pilot lost control of the aircraft at a late stage of the approach due either to disorientation, distraction, incapacitation, or a combination of these conditions.
Final Report: