Crash of a Swearingen SA227AC Metro III in Barcelona: 2 killed

Date & Time: Jul 28, 1998 at 0052 LT
Type of aircraft:
Operator:
Registration:
EC-FXD
Flight Type:
Survivors:
No
Schedule:
Palma de Mallorca - Barcelona
MSN:
AC-651
YOM:
1986
Flight number:
SWT704
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4500
Captain / Total hours on type:
4132.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
1769
Aircraft flight hours:
14748
Circumstances:
Flight SWT704, a cargo flight from Palma de Mallorca to Barcelona, was to be used by the crew as an instruction flight. The co-pilot, who that day was flying for the first time since 20th March 1998, and who was sitting in the left-hand seat, would thus carry out a refresher flight as "First officer under supervision", in accordance with the operator's procedures. At first, it had been planned that the aircraft should carry out a missed approach with one engine on its arrival at Barcelona Airport. However, for a runway 25 approach this was very difficult and the captain decided to postpone this manoeuvre. It was then decided to carry out a standard approach leaving the glide path a little above and then stopping the engine. They would then raise the landing gear and flaps by increments. The captain added: "As soon as we're without control, we'll restore it" (the engine). The approach to runway 25 was also normal. At 00:47:10 they contacted the Barcelona control tower, which indicated that they were number 1, that they should continue and that they should notify "established in final". Afterwards, they extended the landing gear and flaps. At 22:49:55 h, the captain notified the control tower that they were established in final. The tower indicated that they should continue, that a flight was leaving runway 25 and that it would call them immediately. At that moment, the Metro was at a height of some 1400 feet, at some 6 nm (about 3 minutes at 120 kt) from the runway threshold. At 22:50:03 h, with gear and flaps down, the instructor said "Well, engine stop" to which the copilot replied: "Come on, landing gear up". Contrary to normal practice, the right engine was shut down completely and the prop was feathered. It's usual practice to retard the throttles to idle to simulate zero thrust for that engine. When the co-pilot pushed the wrong pedal, the plane deviated to the right. The captain then tried to start the engine again. This failed however because due to the seizing of the guide rod bushing of the propeller pitch change mechanism, the pitch varying mechanism did not take the blades to the necessary pitch for start-up. The captain then said: "Well, I am taking out the engine again. I've raised the flap for you. Now flap by increments...". A few moments later the copilot asked "I continue with the approach, don't I?" to which the captain replied in the affirmative and added that they had been authorized to land and that they were going to land with one engine. At 22:51:09 he again confirmed "Well, just continue with one engine" and appeared to give general instructions on how to carry out a missed approach or what to do when near the runway. At 22:52:01, the captain said "landing gear", the co-pilot said "landing gear now" and the captain then confirmed "coming down". The stall warning then began to sound. The aircraft turned off to the right of the ILS localizer and adopted a position of almost 90° of roll to the left, then a position of 90° of roll to the right whilst continuing to lose height and then again took up a position of 90° of roll to the left. Finally, the left wing struck the ground and then the aircraft crashed first into the outside barrier of highway B-203 which runs round the edge of the Airport and then the perimeter fence, finally coming to a halt at some 250 m from the threshold of runway 25 and some 100 metres to the right of the runway axis. The wreckage of the aircraft burst into flames.
Probable cause:
It is considered that the probable cause of the accident was the loss of control of the aircraft due to an excessive reduction of speed at low height, after having extended the landing gear, with an intermediate flap position, and with the right engine stopped and its propeller pitch close to feather.
Final Report:

Crash of a Swearingen SA227AC Metro III in Santa Fe

Date & Time: Jun 3, 1998 at 0722 LT
Type of aircraft:
Operator:
Registration:
LV-WIL
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires – Santa Fe – Posadas
MSN:
AC-537
YOM:
1983
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Santa Fe-Sauce Viejo Airport by night, the crew was informed about poor weather conditions at destination. The visibility was estimated to be 30 metres in foggy conditions, well below minimums. As the crew elected to attempt an approach, he as cleared for and ILS approach to runway 03. On short final, the aircraft descended below the MDA and struck the ground 430 metres short of runway threshold. On impact, it lost its undercarriage and slid for another 180 metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the crew descended below the established minima during an instrument approach until the aircraft impacted terrain. The following contributing factors were identified:
- Inadequate flight planning, since there was reduced visibility at Sauce Viejo Airport from 01:00 hrs,
- Inappropriate request from the captain who attempted to make an approach in below minima weather conditions,
- Erroneous decision of the captain, knowing the meteorological conditions, to continue the approach below the decision height.

Crash of a Swearingen SA227AC Metro III in Trinidad

Date & Time: Dec 31, 1997
Type of aircraft:
Operator:
Registration:
CP-2321
Flight Phase:
Survivors:
Yes
Schedule:
Trinidad - La Paz
MSN:
AC-643
YOM:
1986
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, the crew lost control of the airplane that veered off runway, lost its undercarriage and came to rest. All 20 occupants escaped uninjured while the aircraft was written off.

Crash of a Swearingen SA227AC Metro III in Djerba

Date & Time: Jan 11, 1997 at 1900 LT
Type of aircraft:
Operator:
Registration:
EC-GKK
Survivors:
Yes
Schedule:
Madrid – Alicante – Djerba
MSN:
AC-730
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown, the crew started the braking procedure when the aircraft went out of control, veered off runway and came to rest in a ditch. All 21 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Swearingen SA227AC Metro III in Bullhead City

Date & Time: Jan 5, 1997 at 1243 LT
Type of aircraft:
Registration:
N165SW
Survivors:
Yes
Schedule:
Long Beach - Grand Canyon
MSN:
AC-514
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3200
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
640
Copilot / Total hours on type:
56
Aircraft flight hours:
25111
Circumstances:
After executing a missed approach at the Grand Canyon Airport, the pilots diverted to the Bullhead City Airport. The pilots reported that minimal icing conditions were encountered with about 1/8 inch of ice accumulating on the aircraft wings. The pilots stated they cycled the deice boots to shed ice. They did not observe ice on the propeller spinners, and they did not activate the engines' 'override' ignition systems, as required by the airplane's flight manual. Use of 'override' ignition was required for flight into visible moisture at or below +5 degrees Celsius (+41 degrees Fahrenheit) to prevent ice ingestion/flameouts. Subsequently, both engines flamed out as the airplane was on about a 3 mile final approach for landing with the landing gear and flaps extended. The aircraft was destroyed during an off-airport landing.
Probable cause:
Failure of the pilot(s) to use 'override' ignition as prescribed by checklist procedures during an encounter with icing conditions, which subsequently led to ice ingestion and dual engine flame-outs. Factors related to the accident were: the adverse weather (icing) conditions, the accumulation of airframe/engine ice, and lack of suitable terrain in the emergency landing area.
Final Report:

Crash of a Swearingen SA227AC Metro III in Saint George

Date & Time: May 3, 1996 at 1630 LT
Type of aircraft:
Operator:
Registration:
N670PA
Survivors:
Yes
Schedule:
Saint Paul - Saint George
MSN:
AC-613
YOM:
1985
Flight number:
KS661
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19100
Captain / Total hours on type:
5500.00
Aircraft flight hours:
17167
Circumstances:
According to passenger's accounts, the airplane was flying low and approached the runway at an angle. The airplane made a right turn and dragged the right wing on the runway's surface. The airplane landed hard and sheared off the right main landing gear and the nose gear. The weather reported by AWOS was 300 foot overcast with a visibility of 2.5 miles with fog. The Captain stated the airplane drifted to the left side of the runway due to the crosswind, and he executed a right turn to realign with the runway. The cockpit voice recorder indicated that the stall warning horn sounded as the First Officer called for the application of power.
Probable cause:
Failure of the captain to maintain proper altitude and wingtip clearance, while aligning the airplane with the runway before landing. His delay in aligning the aircraft with the runway was a related factor.
Final Report:

Crash of a Swearingen SA227AC Metro III in Rincón de Los Sauces

Date & Time: Jan 25, 1996 at 2115 LT
Type of aircraft:
Operator:
Registration:
LV-AOR
Survivors:
Yes
Schedule:
Chos Malal - Rincón de Los Sauces
MSN:
AC-478
YOM:
1981
Flight number:
NEQ413
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Rincón de Los Sauces Airport, the aircraft struck the ground short of runway threshold. The left main gear collapsed and the airplane slid for few dozen metres then veered off runway and came to rest. All six occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
For unknown reasons, the crew was approaching the airport at an insufficient altitude. The following contributing factors were reported:
- Failure of the operator to consider the restrictions at the destination airport,
- Possible windshear on short final.

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a Swearingen SA227CC Metro 23 in Sioux Lookout: 3 killed

Date & Time: May 1, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
C-GYYB
Survivors:
No
Schedule:
Red Lake - Sioux Lookout
MSN:
CC-827B
YOM:
1993
Flight number:
BLS362
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7330
Captain / Total hours on type:
580.00
Copilot / Total flying hours:
2810
Copilot / Total hours on type:
355
Aircraft flight hours:
3200
Circumstances:
Bearskin flight 362, a Fairchild Swearingen Metro 23, departed Red Lake, Ontario, at 1300 central daylight saving time (CDT), with two pilots and one passenger on board, en route to Sioux Lookout on an instrument flight rules (IFR) flight plan. At approximately 30 nautical miles (nm) north of Sioux Lookout, the flight was cleared by the Winnipeg area control centre (ACC) for an approach to the Sioux Lookout airport. Air Sandy flight 3101, a Piper Navajo PA-31, departed Sioux Lookout at 1323 with one pilot and four passengers on board en route to Red Lake on a visual flight rules (VFR) flight. The pilot of Air Sandy 3101 reported clear of the Sioux Lookout control zone at 1326. No other communication was heard from the Air Sandy flight. At 1315 the Winnipeg ACC controller advised the Sioux Lookout Flight Service specialist that Bearskin 362 was inbound from Red Lake, estimating Sioux Lookout at 1332. At 1327, Bearskin 362 called Sioux Lookout Flight Service Station (FSS) and advised them they had been cleared for an approach and that they were cancelling IFR at 14 nm from the airport. At 1328, as Sioux Lookout FSS was giving an airport advisory to Bearskin 362, the specialist heard an emergency locator transmitter (ELT) emit a signal on the emergency frequencies. Moments later, the pilot of Bearskin 305, a Beechcraft B-99 in the vicinity of Sioux Lookout, advised the specialist that he had just seen a bright flare in the sky and that he was going to investigate. The pilot of Bearskin 305 stated that the flare had fallen to the ground and a fire was burning in a wooded area. A communications search was initiated to locate Bearskin 362, but the aircraft did not respond. A Search and Rescue aircraft from Trenton, Ontario, and an Ontario Ministry of Natural Resources (MNR) helicopter were dispatched to the site. The source of the fire was confirmed to be the Air Sandy aircraft. The MNR helicopter noticed debris and a fuel slick on a nearby lake, Lac Seul. It was later confirmed that Bearskin 362 had crashed into the lake. (See Appendix A.) The two aircraft collided in mid-air at 1328 during the hours of daylight at latitude 50º14'N and longitude 92º07'W, in visual meteorological conditions (VMC). All three persons on board the Bearskin aircraft and all five persons on board the Air Sandy aircraft were fatally injured.
Probable cause:
Neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Final Report: