Crash of a Piper PA-31-350 Navajo Chieftain in Kiowa: 2 killed

Date & Time: Jun 5, 2000 at 1031 LT
Operator:
Registration:
N67BJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Denver - Denver
MSN:
31-7952250
YOM:
1979
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3900
Aircraft flight hours:
11279
Circumstances:
The purpose of the flight was for the instructor pilot to administer second-in-command (SIC) flight training to the commercial pilot in the twin-engine aircraft. According to the training manual, SIC training encompassed 4 hours of normal and emergency flight maneuvers to include stalls in the landing and takeoff configuration and while turning at a 15-30 degree bank. A witness heard the airplane's engines and observed the airplane from her driveway. The witness stated that as "the [engine] noise was getting louder and louder, I spotted it spiraling downward." The witness thought that the airplane was performing aerobatics; however, the airplane was getting too close to the ground. The witness heard a loud thud, and approximately 3 seconds later, she heard a loud boom and saw black smoke billow up. Another witness stated that she observed the airplane "going nose first straight down and spinning...counterclockwise." She thought the airplane was performing aerobatic maneuvers; however, the airplane did not stop descending. The airplane disappeared behind trees and the witness heard a loud explosion and saw smoke. She added that she did not observe what the airplane was doing prior to seeing it in a "downward spiral." Radar data depicted the airplane at 8,400 feet msl for the last 2 minutes and 26 seconds of the flight. The recorded aircraft ground speed during that time period fluctuated between 75 and 59 knots. The final radar returns depicted the airplane as making a 180 degree turn before radar contact was lost. No mayday calls were received from the airplane. The airplane impacted the ground in a near wings level attitude and was consumed by a post-crash fire. No anomalies were noted with the airplane or its engines during a post-accident examination. It is unknown which of the pilots was flying the airplane at the time of the accident.
Probable cause:
The flight instructor's failure to maintain aircraft control while practicing stall maneuvers, which resulted in an inadvertent spin.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Whyalla: 8 killed

Date & Time: May 31, 2000 at 1905 LT
Operator:
Registration:
VH-MZK
Survivors:
No
Schedule:
Adelaide - Whyalla
MSN:
31-8152180
YOM:
1981
Flight number:
WW904
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2211
Captain / Total hours on type:
113.00
Aircraft flight hours:
11837
Circumstances:
On the evening of 31 May 2000, Piper Chieftain, VH-MZK, was being operated by Whyalla Airlines as Flight WW904 on a regular public transport service from Adelaide to Whyalla, South Australia. One pilot and seven passengers were on board. The aircraft departed at 1823 central Standard Time (CST) and, after being radar vectored a short distance to the west of Adelaide for traffic separation purposes, the pilot was cleared to track direct to Whyalla at 6,000 ft. A significant proportion of the track from Adelaide to Whyalla passed over the waters of Gulf St Vincent and Spencer Gulf. The entire flight was conducted in darkness. The aircraft reached 6,000 ft and proceeded apparently normally at that altitude on the direct track to Whyalla. At 1856 CST, the pilot reported to Adelaide Flight Information Service (FIS) that the aircraft was 35 NM south-south-east of Whyalla, commencing descent from 6,000 ft. Five minutes later the pilot transmitted a MAYDAY report to FIS. He indicated that both engines of the aircraft had failed, that there were eight persons on board and that he was going to have to ditch the aircraft, but was trying to reach Whyalla. He requested that assistance be arranged and that his company be advised of the situation. About three minutes later, the pilot reported his position as about 15 NM off the coast from Whyalla. FIS advised the pilot to communicate through another aircraft that was in the area if he lost contact with FIS. The pilot’s acknowledgment was the last transmission heard from the aircraft. A few minutes later, the crew of another aircraft heard an emergency locater transmitter (ELT) signal for 10–20 seconds. Early the following morning, a search and rescue operation located two deceased persons and a small amount of wreckage in Spencer Gulf, near the last reported position of the aircraft. The aircraft, together with five deceased occupants, was located several days later on the sea–bed. One passenger remained missing.
Probable cause:
Engine operating practices:
• High power piston engine operating practices of leaning at climb power, and leaning to near ‘best economy’ during cruise, may result in the formation of deposits on cylinder and piston surfaces that could cause preignition.
• The engine operating practices of Whyalla Airlines included leaning at climb power and leaning to near ‘best economy’ during cruise.
Left engine:
The factors that resulted in the failure of the left engine were:
• The accumulation of lead oxybromide compounds on the crowns of pistons and cylinder head surfaces.
• Deposit induced preignition resulted in the increase of combustion chamber pressures and increased loading on connecting rod bearings.
• The connecting rod big end bearing insert retention forces were reduced by the inclusion, during engine assembly, of a copper–based anti-galling compound.
• The combination of increased bearing loads and decreased bearing insert retention forces resulted in the movement, deformation and subsequent destruction of the bearing inserts.
• Contact between the edge of the damaged Number 6 connecting rod bearing insert and the Number 6 crankshaft journal fillet resulted in localised heating and consequent cracking of the nitrided surface zone.
• Fatigue cracking in the Number 6 journal initiated at the site of a thermal crack and propagated over a period of approximately 50 flights.
• Disconnection of the two sections of the journal following the completion of fatigue cracking in the journal and the fracture of the Number 6 connecting rod big end housing most likely resulted in the sudden stoppage of the left engine.
Right engine:
The factors that were involved in the damage/malfunction of the right engine following the left engine malfunction/failure were:
• Detonation of combustion end-gas.
• Disruption of the gas boundary layers on the piston crowns and cylinder head surface increasing the rate of heat transfer to these components.
• Increased heat transfer to the Number 6 piston and cylinder head resulted in localised melting.
• The melting of the Number 6 piston allowed combustion gases to bypass the piston rings.
The flight:
The factors that contributed to the flight outcome were:
• The pilot responded to the failed left engine by increasing power to the right engine.
• The resultant change in operating conditions of the right engine led to loss of power from, and erratic operation of, that engine.
• The pilot was forced to ditch the aircraft into a 0.5m to 1m swell in the waters of Spencer Gulf, in dark, moonless conditions.
• The absence of upper body restraints, and life jackets or flotation devices, reduced the chances of survival of the occupants.
• The Emergency Locator Transmitter functioned briefly on impact but ceased operating when the aircraft sank.
Final Report:

Crash of a Piper PA-31-350 Panther II in Zurich: 1 killed

Date & Time: May 26, 2000 at 2023 LT
Operator:
Registration:
HB-LTC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zurich - Geneva
MSN:
31-7952003
YOM:
1979
Flight number:
HBLTC
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1119
Captain / Total hours on type:
9.00
Aircraft flight hours:
8387
Circumstances:
On 25 and 26 May 2000 aircraft HB-LTC was used for a commercial flight from Zurich to Béziers (F) and back. To this end, the pilot made a positioning flight from Geneva to Zurich on 24 May 2000. The reconstruction of the following events is based on recorded radio conversations and witness statements. On 25 May 2000 at approx. 07:20 hrs, the pilot placed a telephone order with the refuelling service of Jet Aviation Zurich AG. According to statements from aircraft refuelling attendant A concerned, the pilot asked for the aircraft to be fully refuelled with aviation gasoline (AVGAS) for a flight to France. When aircraft refuelling attendant A arrived at the aircraft, the pilot was present. The refuelling attendant saw the winglets on the HB-LTC and asked the pilot whether the machine had been modified and therefore needed jet kerosene. Before the pilot could even answer, the refuelling attendant realised, from the square engine housings, that the machine was equipped with reciprocating engines. The pilot confirmed that HB-LTC had been modified but pointed out that this modification involved only the airframe and that the aircraft had not been converted to turboprop operation. Refuelling attendant A then filled the HB-LTC’s four fuel tanks with 372 l of AVGAS 100LL (low lead). The aircraft was therefore fully refuelled and at that time had 726 l of fuel. Refuelling attendant A later reported that he had not noticed markings which described the types of fuel permitted for this aircraft, either on the wing or on the tank seals. During the refuelling operation, which ended at approx. 07:30 hrs, the pilot was in the cockpit. Nobody observed him draining the tanks after refuelling. The seven passengers for the flight to Béziers (F) arrived on 25 May 2000 at about eight o’clock in the morning at the General Aviation Centre (GAC) at Zurich airport. At 08:18:42 hrs the pilot received start-up clearance from Zurich Apron (ZRH APR) and at 08:26:25 hrs indicated that he was ready to taxi. Taxi clearance was granted without delay and the aircraft taxied to the holding point of runway 28. Several passengers later stated that the pilot carried out a run up of the engines while the following time of waiting. At 08:32:01 hrs HB-LTC indicated to aerodrome control (Zurich Tower – ZRH TWR) that it was ready to take off. The aircraft was queued in the traffic and was cleared for take-off at 08:45:27 hrs. The aircraft landed in Béziers (F) some two hours later. On 26 May 2000 between 15:35 and 15:45 hrs HB-LTC was refuelled in Béziers with 107 l of AVGAS 100LL. The aircraft then flew with the same passengers from Béziers (F) back to Zurich, where it landed at 19:10 hrs. Before the flight back to Geneva, the pilot obviously decided to refuel. According to the statements of aircraft refuelling attendant B at approx. 19:45 hrs the pilot ordered “Kraftstoff JET-A1” by telephone. Unlike the telephone conversations of air traffic control at Zurich airport, incoming and outgoing telephone calls made to and from the refuelling service of Jet Aviation Zurich AG were not recorded. The precise wording of the pilot’s fuel order cannot therefore be established with certainty. Aircraft refuelling attendant B then forwarded the order by radio to his colleague, aircraft refuelling attendant C. A third aircraft refuelling attendant D heard on his radio how aircraft refuelling attendant B gave the instruction to aircraft refuelling attendant C to refuel aircraft HB-LTC with JET A-1 fuel. Then aircraft refuelling attendant C drove tanker FL 7 to HB-LTC, which was parked in GAC Sector 1. According to his statements, he positioned the tanker with its right-hand side in front of the aircraft so that he could reach the filler caps on both wings using the hose affixed to that side of the tanker. Then aircraft refuelling attendant C, still next to the tanker, began to complete the delivery note, while the pilot came up to him and indicated the desired quantity of fuel in English. The pilot gave him a credit card and aircraft refuelling attendant C then explained to him that after refuelling he would have to complete the transaction in the office. The pilot remarked that he had a slot. Aircraft refuelling attendant C later stated that this gave him to understand that the pilot did not have much time. The aircraft refuelling attendant replied to the pilot that he would only need an additional two or three minutes. Because it had started to rain shortly before refuelling, the pilot evidently withdrew into the aircraft after his conversation with aircraft refuelling attendant C. According to his partner, the pilot conducted a brief conversation with her from his mobile telephone during this phase. As the investigation showed, this telephone call took place between 19:50:06 and 19:51:28 hrs. In the meantime, aircraft refuelling attendant C had connected HB-LTC to the tanker and then pumped 50 l of JET A-1 fuel into each of the two inboard main cells. The aircraft refuelling attendant later stated that he had not noticed markings or labels which described the permitted types of fuel for this aircraft, either on the tank seals or in the vicinity of the tank openings. He then drove the tanker to the office, debited the credit card and returned it with the receipt and the delivery note to the aircraft. He presented the debit slip and the delivery note to the pilot for signature. In the process the aircraft refuelling attendant asked the pilot what aircraft type HB-LTC was. The pilot answered that his aircraft was a modified PA31. The aircraft refuelling attendant then entered “PA31” on the delivery note and then gave the pilot the carbon copy. At 20:08:44 hrs the pilot made radio contact with Zurich Clearance Delivery (ZRH CLD) air traffic control and received departure clearance with the instruction to change to the ZRH APR frequency for start-up clearance. The apron gave HB-LTC start-up clearance at 20:10:00 hrs. Three minutes and 50 seconds later the pilot requested taxi clearance and was then instructed to taxi to the holding point of runway 28. After the transfer to ZRH TWR at 20:15:02 hrs the pilot stated he was ready for take off at 20:17:30 hrs. A short time after this he was able to line up runway 28 and at 20:20:58 hrs ZRH TWR gave him take-off clearance. According to witness statements, HB-LTC took off normally and went into a climb. In the region of runway intersection 28/16 and at an altitude of approx. 50 m AGL the aircraft stopped climbing, maintained level flight briefly and began to descend slightly. At the same time, HB-LTC began to make a gentle right turn and overflew the woods to the north of runway 28. Because of this unusual flight pattern, the duty aerodrome controller (ADC) at 20:22:08 hrs asked the pilot whether everything was normal: “Tango Charlie, normal operations?” The pilot replied in the negative: “(Ne)gative, Hotel Tango Charlie!” In this phase, the aircraft began to make a left turn with a high bank angle and witnesses observed that the landing gear was lowered. At 20:22:21 hrs the pilot radioed that he was in an emergency situation: “Mayday, Mayday, Mayday, Hotel Tango Charlie”. During the first 90° of the turn, HB-LTC descended only slightly. After crossing the extended centerline of runway 28 the aircraft increasingly lost height in the tight left turn. When the aircraft had almost completed the full turn, its bank attitude began to reduce. At a height of approx. 10 m AGL HB-LTC collided with the trees in a copse. The aircraft passed through the copse and came to rest upside down in the “Glatt” river. The pilot was fatally injured on impact. Coordinates of the final position of the wreck: 682 700/256 700, elevation 420 m AMSL corresponding to 1378 ft AMSL.
Probable cause:
The investigation established the following causal factors for the accident:
• A misunderstanding occurred when the fuel was ordered.
• The refuelling attendant concerned did not notice the fuel grade rating placards attached to the aircraft.
• The refuelling attendant concerned did not realise that the aircraft was equipped with reciprocating engines.
• The pilot did not notice the fuel grade rating placards on the tanker vehicle.
• The pilot did not realise the incorrect refuelling on the receipt for the fuel provision.
The following factors allowed or favoured the occurrence of the accident:
• The delivery nozzle on the filler gun was of an outside diameter which allowed the aircraft involved in the accident to be refuelled.
• The level of training and knowledge of the refuelling personnel concerned was inadequate.
• The Federal Office for Civil Aviation never inspected the refuelling operation before the accident.
• Until the time of the accident, the Federal Office for Civil Aviation had issued no regulations on the training of refuelling personnel, the size of delivery nozzles and tank openings on aircraft or on the identification of filler guns and tank openings.
The following points may have exacerbated the outcome of the accident:
• The pilot decided on an about turn which brought him onto a collision course with obstacles.
• The retention mechanism of the safety belt was not working.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Manzini: 2 killed

Date & Time: Apr 2, 2000
Registration:
ZS-NGV
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
31-7952071
YOM:
1979
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following a night takeoff from Manzini-Matsapha Airport, the twin engine aircraft struck power cables and crashed. The captain survived while the copilot and the passenger, a company mechanic, were killed. It was reported that a turbocharger fitted to one of the engines was not compliant. Also, the pilot's licence was forged. Poor engine maintenance was identified.

Crash of a Piper PA-31-350 Navajo Chieftain in Stony Rapids

Date & Time: Feb 27, 2000 at 2200 LT
Operator:
Registration:
C-FATS
Survivors:
Yes
Schedule:
Edmonton - Stony Rapids
MSN:
31-7952072
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
1450.00
Circumstances:
The Piper Navajo Chieftain PA-31-350, serial number 31-7952072, departed Edmonton, Alberta, on an instrument flight rules charter flight to Stony Rapids, Saskatchewan, with one pilot and six passengers on board. The pilot conducted a non-directional beacon approach at night in Stony Rapids, followed by a missed approach. He then attempted and missed a second approach. At about 2200 central standard time, while manoeuvring to land on runway 06, the aircraft struck trees 3.5 nautical miles west of the runway 06 button and roughly one quarter nautical mile left of the runway centreline, at an altitude of 1200 feet above sea level. The aircraft sustained substantial damage, but no fire ensued. The pilot and one passenger were seriously injured, and the remaining five passengers sustained minor injuries. Canadian Forces search and rescue specialists were air-dropped to the site at 0300 and provided assistance to the pilot and passengers. Local ground search parties later assisted with the rescue.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot executed a missed approach on his first NDB approach, and, during the second missed approach, after momentarily seeing the runway, he decided to conduct a visual approach, descending below MDA in an attempt to fly under the cloud base.
2. In flying under the cloud base during the visual portion of his approach, the pilot likely perceived the horizon to be lower on the windscreen than it actually was.
3. There was no indication that there was any form of pressure from management to influence the pilot to land at the destination airport. However, the pilot may have chosen to land in Stony Rapids because he had an early flight the following day, and he did not have the keys for the accommodations in Fond-du-Lac.
Findings as to Risk:
1. No scale was available to the pilot in Edmonton for weighing aircraft loads.
2. The maximum allowable take-off weight of the aircraft was exceeded by about 115 pounds, and it is estimated that at the time of the crash, the aircraft was 225 pounds below maximum landing weight. The aircraft's centre of gravity was not within limits at the time of the crash.
3. The rear baggage area contained 300 pounds of baggage, 100 pounds more than the manufacturer's limitation.
4. Two screws were missing from each section of the broken seat track to which the anchor points were attached.
5. Cargo net anchorage system failure contributed to passenger injuries.
6. The stitching failed on the seat belt's outboard strap that was mounted on the right, middle, forward-facing cabin seat.
Other Findings:
1. Hand tools were required to access the ELT panel, since the cockpit remote switch could not be accessed.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Williston Lake

Date & Time: Feb 7, 2000 at 1055 LT
Operator:
Registration:
C-GBFZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Mackenzie – Bear Valley – Tsay Keh – Mackenzie
MSN:
31-7752151
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Captain / Total hours on type:
1500.00
Circumstances:
The pilot of a Piper PA-31-350 Navajo Chieftain, serial number 31-7752151, encountered an area of heavy snow and reduced visibility while on a visual flight rules flight from Bear Valley, British Columbia, logging camp to Tsay Keh. The pilot was unable to maintain visual references and executed a 180-degree turn in an attempt to regain visual flight. Shortly after completing the turn, at about 1055 Pacific standard time, the aircraft collided with the ice on the Peace Reach Arm of Williston Lake, British Columbia. The pilot was the sole occupant of the aircraft and received serious injuries. There was no fire. The aircraft was destroyed during the collision.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Weather conditions at the time and location of the occurrence were not suitable for visual flight.
2. While the pilot was attempting to regain visual flight, he allowed the aircraft to descend and it struck the ice surface. The weather and surface conditions were such that it would have been virtually impossible to visually detect the ice surface.
Other Finding:
1. In the absence of en route weather reporting facilities, the pilot could only estimate weather conditions based on the area forecast and informal reports received from lay personnel.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Johannesburg: 10 killed

Date & Time: Dec 6, 1999 at 0706 LT
Registration:
ZS-OJY
Flight Phase:
Survivors:
No
Schedule:
Johannesburg - Oranjemund
MSN:
31-7405210
YOM:
1974
Flight number:
FC350
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
1444
Captain / Total hours on type:
445.00
Aircraft flight hours:
8422
Circumstances:
The charter operator was involved in a weekly operation to transport computer programmers and training staff, from a Johannesburg company, from Rand Airport to Oranjemund in Namibia. The outward leg of the flights to Oranjemund took place on the Monday morning and the pilot and aircraft stayed at Oranjemund for the week. The return flight to Johannesburg usually took place on the Friday afternoon. On the morning of the accident flight the set time of departure was 0500z. The passengers were assisted through the process of passport control, boarding and settling in by the operator's staff. The baggage was put next to the aircraft. According to a witness the pilot carried out the loading of the baggage. An instrument flight plan was filed and the pilot obtained departure clearance before the aircraft was taxied to the holding point. According to the air traffic controller, the take-off run was normal for this type of aircraft. Shortly after take-off the pilot declared an engine failure and requested to be routed back to land on the runway. Seconds later the pilot communicated they were going to crash. Several witnesses stated that the aircraft was very low when it passed over the highway close to the accident site. One of the witnesses stated that he noticed the right-hand engine stopped and he could see the blades of the propeller. The fire fighting services were alerted. It was apparent by the smoke that the aircraft crashed on an extended line of Runway 29. The accident took place at 0506z in daylight conditions. All 10 occupants were killed.
Probable cause:
The following findings were identified:
- The precipitative cause of this accident was the failure of the exhaust pipe segment, which caused the right–hand engine to lose power/fail.
- The overloaded condition of the aircraft was thus a highly significant contributory factor.
- The pilot operating the aircraft in an overloaded condition is regarded as a significant contributing factor.
- The company’s lack of flight operations management experience, professional flight standards supervision and an operational safety management program are regarded as significant contributing factors.
- The anomalies noted in regulatory oversight of the operator (airworthiness and flight operations surveillance) by the CD:CAA and CAA are regarded as possible contributing factors.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain on Gass Peak: 1 killed

Date & Time: Oct 14, 1999 at 1946 LT
Operator:
Registration:
N1024B
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
North Las Vegas – Sacramento
MSN:
31-7652107
YOM:
1976
Flight number:
AMF121
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2103
Captain / Total hours on type:
250.00
Aircraft flight hours:
14048
Circumstances:
The airplane collided with mountainous terrain during climb to cruise on a night departure. The pilot of the on-demand cargo flight was brought in off reserve to replace the scheduled pilot who was ill. The flight was behind schedule because the cargo was late. When the instrument flight release created further delay, the pilot opted to depart into the clear, dark night under visual flight rules (VFR) with the intention of picking up his instrument clearance when airborne. When clearing the flight for takeoff, the tower controller issued a suggested heading of 340 degrees, which headed the aircraft toward mountainous terrain 11 miles north of the airport. The purpose of the suggested heading was never stated to the pilot as required by FAA Order 7110.65L. After a frequency change to radar departure control, the controller asked the pilot 'are you direct [the initial (route) fix] at this time?' and the pilot replied, 'we can go ahead and we'll go direct [the initial fix].' A turn toward the initial fix would have headed the aircraft away from high terrain. The controller then diverted his attention to servicing another VFR aircraft and the accident aircraft continued to fly heading 340 degrees until impacting the mountain. ATC personnel said the 340-degree heading was routinely issued to departing aircraft to avoid them entering Class B airspace 3 miles from the airport. The approach control supervisor said this flight departs daily, often VFR, and routinely turns toward the initial fix, avoiding mountainous terrain. When the pilot said that he would go to the initial fix, the controller expected him to turn away from the terrain. Minimum Safe Altitude Warning (MSAW) was not enabled for the flight because the original, instrument flight plan did not route the aircraft through this approach control's airspace and the controller had not had time to manually enter the flight data. High terrain was not displayed on the controller's radar display and no safety alert was issued.
Probable cause:
The failure of the pilot-in-command to maintain separation from terrain while operating under visual flight rules. Contributing factors were the improper issuance of a suggested heading by air traffic control personnel, inadequate flight progress monitoring by radar departure control personnel, and failure of the radar controller to identify a hazardous condition and issue a safety alert.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain on Mt Mauna Loa: 10 killed

Date & Time: Sep 25, 1999 at 1726 LT
Operator:
Registration:
N411WL
Flight Phase:
Survivors:
No
Site:
Schedule:
Kona - Kona
MSN:
31-8352039
YOM:
1983
Flight number:
BIA058
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Captain / Total flying hours:
11500
Aircraft flight hours:
4523
Circumstances:
On September 25, 1999, about 1726 Hawaiian standard time, Big Island Air flight 58, a Piper PA-31-350 (Chieftain), N411WL, crashed on the northeast slope of the Mauna Loa volcano near Volcano, Hawaii. The pilot and all nine passengers on board were killed, and the airplane was destroyed by impact forces and a postimpact fire. The sightseeing tour flight was operating under 14 Code of Federal Regulations Part 135 as an on-demand air taxi operation. A visual flight rules flight plan was filed, and visual meteorological conditions existed at the Keahole-Kona International Airport, Kona, Hawaii, from which the airplane departed about 1622. The investigation determined that instrument meteorological conditions prevailed in the vicinity of the accident site.
Probable cause:
The pilot's decision to continue visual flight into instrument meteorological conditions (IMC) in an area of cloud-covered mountainous terrain. Contributing to the accident were the pilot's failure to properly navigate and his disregard for standard operating procedures, including flying into IMC while on a visual flight rules flight plan and failure to obtain a current preflight weather briefing.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Newnan: 2 killed

Date & Time: Sep 21, 1999 at 0522 LT
Registration:
N27343
Flight Type:
Survivors:
No
Schedule:
Charlotte - Newnan
MSN:
31-7752163
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2000
Captain / Total hours on type:
250.00
Aircraft flight hours:
8340
Circumstances:
The flight was cleared for a localizer approach to runway 32 at Newnan-Coweta County Airport during dark night conditions. About 8 minutes later the pilot reported to air traffic control that he had missed approach and would like to try another approach. The flight was radar vectored to the final approach course and again cleared for the localizer runway 32 approach. The flight was observed on radar to continue the approach until a point about 4 nautical miles from the airport, at which time radar contact was lost. The last observed altitude was 1,600 feet msl. The aircraft collided with 80-foot tall trees, while established on the localizer for runway 32, about 1.3 nautical miles from the runway. About the time of the accident the weather at the airport was reported as a cloud ceiling 200 feet agl, and visibility .75 statute miles. Post crash examination of the aircraft structure, flight controls, engines, propellers, and systems showed no evidence of pre-crash failure or malfunction.
Probable cause:
The pilot's failure to maintain the minimum descent altitude while executing a localizer approach. Contributing factors were low ceilings and dark night conditions as well as the trees.
Final Report: