Crash of a Short 330-200 in Paris: 1 killed

Date & Time: May 25, 2000 at 0252 LT
Type of aircraft:
Operator:
Registration:
G-SSWN
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Paris - Luton
MSN:
3064
YOM:
1981
Flight number:
SSW200
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2240
Captain / Total hours on type:
1005.00
Copilot / Total flying hours:
4370
Copilot / Total hours on type:
14
Aircraft flight hours:
15215
Aircraft flight cycles:
19504
Circumstances:
The Short was departing Paris-Roissy-CDG Airport on a cargo service to Luton with two pilots on board. The crew were cleared to depart cargo stand N51 and proceed to runway 27 at 02:38. Around the same time Air Liberté Flight 8807 (an MD-83, F-GHED) also taxied to runway 27 for a flight to Madrid. At 02:44 the Charles de Gaulle ground controller asked Streamline 200 if they wished to enter runway 27 at an intermediate taxiway; the crew asked for and were granted to enter Taxiway 16. At 02:50:49 the tower controller cleared the MD-83 for takeoff: "Liberté 8807, autorisé au décollage 27, 230°, 10 à 15 kts.". The controller then immediately told the Shorts to line up and wait: "Stream Line two hundred line up runway 27 and wait, number two". As the MD-83 was travelling down the runway, the Shorts started to taxi onto the runway. At a speed of about 155 knots the left wing of MD-83 slashed through the cockpit of the Shorts plane; the MD-83 abandoned takeoff.
Probable cause:
The following findings were identified:
- Firstly, by the LOC controller’s erroneous perception of the position of the aircraft, this being reinforced by the context and the working methods, which led him to clear the Shorts to line up,
- Secondly, by the inadequacy of systematic verification procedures in ATC which made it impossible for the error to be corrected,
- Finally, by the Shorts’ crew not dispelling any doubts they had as to the position of the 'number one' aircraft before entering the runway.
Contributory factors include:
- Light pollution in the area of runway 27, which made a direct view difficult for the LOC controller,
- Difficulty for the LOC controller in accessing radar information: the ASTRE image was difficult to read and the AVISO image not displayed at his control position,
- The use of two languages for radio communications, which meant that the Shorts crew were not conscious that the MD 83 was going to take off,
- The angle between access taxiway 16 and the runway which made it impossible for the Shorts crew to perform a visual check before entering the runway,
- The lack of coordination between the SOL and LOC controllers when managing the Shorts, exacerbated by the presence of a third party whose role was not defined,
- A feedback system which was recent and still underdeveloped.
Final Report:

Crash of a Short 330-100 in La Lopé

Date & Time: Apr 23, 1998 at 0800 LT
Type of aircraft:
Registration:
TR-LEH
Survivors:
Yes
Schedule:
Libreville - Booué
MSN:
3075
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While approaching Booué Airport, the crew encountered poor weather conditions. As a landing was impossible in such conditions, the crew decided to return to Libreville but en route, ATC confirmed that weather was poor and the crew decided to divert to La Lopé Airport. After landing on a wet runway surface (La Lopé runway is 800 metres long), the aircraft encountered difficulties to stop within the remaining distance and overran. While contacting soft ground, the nose gear collapsed then the aircraft rolled for about 50 metres before coming to rest in a rocky area. All 16 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Short 330-300 in Liverpool

Date & Time: Jan 3, 1997 at 0042 LT
Type of aircraft:
Operator:
Registration:
G-ZAPC
Flight Type:
Survivors:
Yes
Schedule:
Exeter - East Midlands
MSN:
3023
YOM:
1978
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3015
Captain / Total hours on type:
900.00
Circumstances:
The aircraft departed Exeter at 2237 hrs where the weather was fair with scattered cloud at 1500 feet. After climbing uneventfully through cloud to FL 90 the aircraft cruisedin clear, smooth air. In the cruise the co-pilot noticed that his vertical speed indicator was displaying a slight rate of climb although the aircraft was in level flight but this and a spurious hydraulic warning were the only anomalies. As the aircraft approached East Midlands airport the runway visual range there was below the approach minima and several aircraft were holding awaiting an improvement in the visibility. G-ZAPC descended to 2,500 ft and held in clear air over the Lichfield NDB for about 45 minutes until the fuel state dictated a diversion to Liverpool. On diversion the aircraft was initially cleared direct to the Whitegate NDB and then Wallasey VOR at FL 40. At this level the crew could see ground features in good visibility until they entered cloudas they descended through 3,500 feet whilst being radar vectored for an approach to Liverpool Airport. The cloud was stratiform in character and did not appear to contain precipitation or significant turbulence. At Liverpool airport the cloud base was 6/8at 1,100 feet, the visibility 12 km, the air temperature +1°Cand the surface wind was 060°/8 kt. There is an ILS localiser on Runway 09 but no glidepath transmitter so a LOC DME approach is normally flown. Although the DME antenna is mid-way along the runway, the DMErange is set to read zero at the runway displaced threshold. The pilot flies the localiser in azimuth and adjusts his height according to his pressure altimeter; the 3° glidepath commences at 1,610 feet QNH from 5 nm DME with check heights at 4, 3, 2 and 1 nm DME. On the north side of the runway 329 metres from the threshold there are 4 PAPI (Precision Approach Path Indicator)lights which are set to a glidepath of 3°. During the approach to Runway 09 at Liverpool all the anti-icing services were switched on and operating except for the wing de-icing boots which, having seen no ice on the wings,the commander decided not to employ, and the ice detector which he considered unreliable. The approach proceeded normally andthe aircraft descended out of cloud at about 1,100 feet having been in cloud for about 10 minutes. When the commander viewed the PAPIs at 1 DME"all four lights had a pink tinge". Thinking he might be slightly low relative to the approach glidepath, he asked the co-pilot to specify the correct height at 1 DME which was 410feet. At the time the commander's pressure altimeter, which was set to the QNH of 1019 mb, indicated that the aircraft was slightly high and so he made a small correction to the flight path which resulted in three red PAPI lights and one white light. The commander also decided to touch down slightly beyond the runway identifier numbers which are a few metres beyond the 'piano keys' that identify the threshold. The aircraft was cleared to land with a wind of "Easterly at 10 kt" and on short finals the commander asked for full flap. He then allowed the speed to bleed back from the approach speed of between 110 and 120 KIAS towards the threshold speed of 90 KIAS without moving the throttles from their approach power setting. According to both crew members and the passenger who was seated in the 'jump seat', the aircraft crossed over the end of runway at between 88 and 90 KIAS. Some 20 to 30 feet above the runway the commander noticed that the flight controls felt 'sloppy' as if the aircraft's speed was unusually low but there was no hint of a stall warning or stick shaker activation. At much the same time all three persons on board felt the aircraft sink rapidly; the commander pulled back on the control column but he was unable to arrest the high rate of descent and the aircraft struck the runway very hard. The right wing dropped as the right main gear collapsed and the aircraft veered to the right off the runway onto the grass. The ground was frozen hard and the aircraft came to a halt without incurring further significant damage. The crew informed ATC that they were unhurt before securing the aircraft whilst ATC activated the airport's emergency services. On leaving the aircraft the commander inspected the wings for ice accretion. He noticed a thin layer of clear,watery ice along the leading edges across the pneumatic de-icing boots from top to bottom. The ice layer could be wiped off with one finger and was no more than one eight of an inch thick. Throughout the flight there had been no visible signs of ice accretion on the wings or the windscreen wiper. Consequently, the commander had not increased the threshold speed to compensate for ice accretion.
Probable cause:
From the available evidence it appears probable that the aircraft developed a high rate of descent from a height of 20 to 30 feet above the runway without producing a stall warning. The following causal factors were considered: wind shear; wake turbulence; pitot-static system errors; low airspeed during the final stages of the approach; and significant ice accretion on the airframe. Wind shear was discounted because numerous wind readings showed the normal slight variation in direction but a consistent wind speed, and there were no obstacles such as hangars upwind of the threshold. Wake turbulence was discounted because the preceding aircraft had landed 19 minutes before GZAPC. The pitot-static systems were checked to be leak free and all relevant instruments were shown to be accurate. It was also established that all pitot head, static plate and stall warning heaters were serviceable. A favourable comparison of the approach profile with those of the preceding four aircraft indicated that there was no evidence of static pressure errors. The calculated airspeeds from radar were consistent with thespeeds reported by the crew for the initial approach suggesting that itot errors were not significant. Thus, unless icing, for example, had affected these systems at a late stage of the approach,erroneous instrument readings were considered unlikely. The final approach was flown at about the correct airspeed but there was a trend within the radar data,for the last mile of the approach, for the airspeed to reduce towards the stalling speed. However the data was too coarse to provide exact speeds and the stall warning system did not activate. The likelihood of significant airframe icing was discounted for several reasons including: the commander's statement; photographs taken of the aircraft shortly after the accident which showed no signs of significant ice accretion; no lumps of ice were found on the runway; and the airframe was icefree when examined by the AAIB despite overnight sub-zero temperatures. There was, therefore, no positive conclusion as to the cause and it remains a possibility that some or all of the above factors, to a small extent, may have combined to produce a high rate of descent while the aircraft was some 20to 30 feet above the runway.
Final Report:

Crash of a Short 330-UTT in Umiujaq

Date & Time: Dec 1, 1993 at 1510 LT
Type of aircraft:
Registration:
C-FPQE
Flight Type:
Survivors:
Yes
Schedule:
Kuujjuarapik - Umiujaq
MSN:
3124
YOM:
1988
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10122
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
10000
Copilot / Total hours on type:
10
Aircraft flight hours:
1323
Circumstances:
The two pilots were transporting Hydro-Québec employees in the aircraft to allow them to check electrical facilities in several villages along the Hudson Bay coast. The aircraft departed
Kuujjuarapik, Quebec, at about 1444 eastern standard time (EST) on a flight to Umiujaq, Quebec, a distance of 86 nautical miles (nm) to the north. The pilot-in-command was flying the aircraft. After the take-off from Kuujjuarapik, the crew contacted the Kuujjuarapik Flight Service Station (FSS) to file a flight notification and request weather information. The crew received three weather reports for Umiujaq from that FSS. The flight was conducted at an altitude of 5,000 feet on an outbound track of 045 degrees from the Kuujjuarapik non-directional beacon (NDB). Thirty miles from Umiujaq, the crew commenced the descent. Seven miles from the village, the aircraft was at an altitude of 700 feet and the crew could see the ground. The crew used a global positioning system (GPS) waypoint to supplement visual navigation (before reaching a downwind position), and continued their step-down procedure to about 200 feet above ground level (agl) on a heading of 25 degrees magnetic (°M). At that altitude, the visibility was reported by the crew to be over one and one-half miles and the crew could recognize references on the ground and position the aircraft for landing. When turning onto the final approach to runway 21, the pilot-in-command initiated a turn with at least 35 degrees of bank angle, and the aircraft stalled. The pilot-in-command initiated a stall recovery and called for full power. The aircraft did not gain sufficient altitude to overfly the rising terrain, and it crashed. The two crew members and two of the passengers sustained minor injuries. They were given first aid treatment at the accident site by other passengers.
Probable cause:
The stalling speed of the aircraft increased due to ice on the leading edge of the wings and because the pilot made a steep turn; the aircraft stalled at an altitude from which the pilot was unable to recover. A contributing factor was the crew's decision to continue the visual approach into Umiujaq despite the weather conditions reported.
Final Report:

Crash of a Short 330-100 in Tortola

Date & Time: May 6, 1993
Type of aircraft:
Operator:
Registration:
VP-LVR
Flight Phase:
Survivors:
Yes
Schedule:
Tortola - San Juan
MSN:
3006
YOM:
1976
Crew on board:
3
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Tortola-Terrance B. Lettsome Airport, the pilot-in-command considered the aircraft behaviour as unsatisfactory and decided to abort. Despite an emergency braking procedure, the aircraft was unable to stop within the remaining distance, overran and came to rest in the sea. All 30 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The decision of the crew to abort the takeoff procedure because the aircraft behaviour was unsatisfactory was unfounded. Investigations did not reveal any mechanical malfunction on the airplane and the crew misjudged the situation, causing the aircraft to enter an uncontrollable roll.

Crash of a Short JC-23A Sherpa in Colquitt: 3 killed

Date & Time: Jul 16, 1992 at 0930 LT
Type of aircraft:
Operator:
Registration:
84-0466
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Cairns AAF - Cairns AAF
MSN:
3113
YOM:
1985
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The Sherpa departed Fort Rucker-Cairns AAF on a training flight, carrying three crew members who were supposed to test the aircraft in special configuration. Two hours and 45 minutes into the flight, while cruising at an altitude of 5,336 feet in good weather conditions, the aircraft became unstable and rolled to the right to an angle of 12° then to the left to an angle of 35°. It entered an uncontrolled descent before crashing in an open field located 4 miles north of Colquitt, bursting into flames. All three occupants were killed. It was determined that control was lost while the aircraft' speed was 89 knots. Originally, the crew was supposed to simulate an engine failure at the altitude of 10,000 feet but apparently encountered problems as the aircraft' speed was dropping by the order of one knot per second before it became unstable. At the time of the accident, the total weight of the aircraft and its CofG were within limits.
Probable cause:
The exact cause of the stall at a speed of 89 knots remains unclear.

Crash of a Short 330-200 near Samos: 34 killed

Date & Time: Aug 3, 1989 at 1530 LT
Type of aircraft:
Operator:
Registration:
SX-BGE
Survivors:
No
Site:
Schedule:
Thessaloniki - Samos - Kos
MSN:
3083
YOM:
1982
Flight number:
ML545
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
31
Pax fatalities:
Other fatalities:
Total fatalities:
34
Circumstances:
The crew started the approach to Samos Airport runway 09 in poor weather conditions. While flying under VFR mode in IMC conditions, the aircraft struck the slope of Mt Kerkis (1,430 meters high) located 25 km northwest of the airport. The aircraft disintegrated on impact and all 34 occupants were killed. At the time of the accident, the visibility was poor and the mountain was shrouded in clouds.
Probable cause:
It was determined that the crew initiated a VFR approach in IMC conditions to runway 09 at Samos Airport. Standard approach to Samos are on runway 27 from the sea but could be completed to runway 09 if the minimum visibility is good at least 3,2 km from threshold.
The following contributing factors were reported:
- Navigation error on part of the crew who deviated by 4 nm from the approach route,
- VFR approach in IMC conditions,
- The weather radar in the cockpit was OFF at the time of the accident,
- The pilot-in-command was completing a steep turn when the aircraft impacted ground,
- Lack of visibility due to low clouds.

Crash of a Short 330-200 in Southend

Date & Time: Jan 11, 1988 at 1244 LT
Type of aircraft:
Operator:
Registration:
G-BHWT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Southend - Biggin Hill
MSN:
3049
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After being parked at Southend Airport for a long time without any maintenance and due to hydraulic problems, it was decided to ferry the aircraft from Southend to Biggin Hill. While taxiing, the nosewheel steering system failed and the crew lost control of the aircraft that veered to the left and collided with a parked British Air Ferries Vickers 806 Viscount registered G-APIM. Both pilots escaped uninjured and both aircraft were damaged beyond repair.
Probable cause:
Corrosion within the emergency brake accumulator had allowed nitrogen to enter the main hydraulic system. In the past, the aircraft had been parked in the open for a considerable time without servicing.