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Crash of a Cessna 550 Citation Bravo in Reinhardtsdorf-Schöna: 2 killed

Date & Time: Feb 14, 2010 at 2038 LT
Type of aircraft:
Operator:
Registration:
OK-ACH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Prague - Karlstad
MSN:
550-1111
YOM:
2005
Flight number:
TIE039C
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1700
Copilot / Total flying hours:
1600
Aircraft flight hours:
1830
Aircraft flight cycles:
1686
Circumstances:
During the early evening, at 1946 hrs, after a flight time of one hour and 50 minutes the airplane came back to Prague, Czech Republic, after a flight to France. For the Pilot in Command (PIC) it was the first flight of the day. The co-pilot left the airplane after the landing and was replaced by the copilot of the subsequent accident flight. The co-pilot had already flown two flights that day - around midday - with a total flight time of one hour and 40 minutes. There were no passengers on board. The aircraft departed Prague at 2008 hrs for a ferry flight to Karlskrona, Sweden. The flight was conducted in accordance with Instrument Flight Rules (IFR). The course of events is described based on the analysis of the recordings of the Flight Data Recorder (FDR), the Cockpit Voice Recorder (CVR), radar and radio communications. The appendix shows two different FDR recording diagrams. Diagram 1 shows the entire flight (time in UTC) and diagram 2 shows the flight from 1918:30 UTC on. Take-off took place on runway 31. The co-pilot was Pilot Flying (PF). The flight was conducted manually, neither of the two autopilots was engaged. From 2012 hrs on, after a right hand turn, the flight proceeded toward the north. The airplane was in climb attitude. At 2014:16 hrs, still in climb, the PIC said "I didn't fly night time for long time". The co-pilot asked: "Have you already experienced a roll during night?" She answered laughing: "Yes, really." He: "Better we won't." She laughing: "Do you enjoy that thing?" Co-pilot: "You are the first one with whom I talked about it, don't tell it [...]." PIC: "Whom shall I not tell?" [...] She again: "I also do it always, but I persuade [...] to do that." Co-pilot: "[...] Bravo does it better." At 2015:00 hrs, during this short conversation, the crew received the instruction from ATC Prague to climb to FL260 and to level off above reporting point DEKOV. The conversation in the cockpit continued. Co-pilot: "Bravo does the roll faster with the ailerons but the spoilers are slower." At 2015:33 hrs ATC repeated the instruction. At 2015:40 hrs the PIC acknowledged the instruction. Between 2017:10 hrs and 2017:20 hrs the airplane rolled about its longitudinal axis; initially to the left up to a bank angle of 30°, and right afterwards to the right up to a bank angle of 20°, then back again to the horizontal. At 2017:20 hrs the PIC responded to it with the words: "Let's go, we are already high enough, you nettle me - come on [...]." At 2017:22rs ATC Prague instructed the crew to contact ATC Munich; at 2017:35 hrs the PIC confirmed the instruction. At 2017:42 hrs she said: "Later but." The co-pilot replied: "Let's do it at higher altitude." At 2018:29 hrs, the PIC contacted ATC Munich. At 2018:36 hrs the crew received the instruction from ATC Munich to climb to FL330. This was confirmed at 2018:44 hrs. Between 2018:51 hrs and 2019:00 hrs the following conversation took place:
- 2018:51 hrs PIC: "Sufficient, is it sufficient?"
- 2018:53 hrs Co-pilot: "For what?"
- 2018:54 hrs PIC: "Sufficient."
- 2018:56 hrs PIC: "The altitude."
- 2018:58 hrs Co-pilot: "For what?"
- 2018:58 hrs PIC: "For that,"
- 2019:00 hrs Co-pilot: "It is sufficient."
At 2019:00 hrs the airplane levelled off in FL270, at 2019:05 hrs the airplane nose moved upward until a pitch angle of about 14° was reached. At 2019:09 hrs the aircraft began to roll about its longitudinal axis to the right. Within 4 seconds the airplane reached the inverted flight attitude and in another 4 seconds it rolled another 90°. Simultaneously the heading changed right toward the east, then toward the south and finally toward the west. During the roll the pitch angle decreased to almost -85° which is almost a vertical nose dive. The computed airspeed increased
significantly. The airplane crashed near Reinhardtsdorf-Schöna, Saxon Switzerland, about 500 m north of the border to the Czech Republic.
Probable cause:
The accident was due to:
- The crew tried to conduct a flight manoeuvre (roll) which is not part of commercial air transport,
- The crew suffered loss of spatial orientation and subsequently did no longer have the ability to recover the flight attitude.
The following factors contributed:
- The pilots were not trained in aerobatics,
- It was night and therefore there were no visual references,
- The relationship between the two pilots resulted in the departure from professional behavior in regard to crew coordination,
- The airplane was neither designed nor certified for aerobatics.
Final Report:

Crash of a Piper PA-31-310 Navajo B in Karlstad: 5 killed

Date & Time: Aug 16, 1992 at 1142 LT
Type of aircraft:
Operator:
Registration:
OY-BZD
Survivors:
Yes
Schedule:
Roskilde - Karlstad
MSN:
31-7401266
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
550
Captain / Total hours on type:
20.00
Aircraft flight hours:
4725
Circumstances:
On approach to Karlstad Airport, the pilot informed ATC he was low on fuel. Shortly later, he declared an emergency when the both engines stopped. The aircraft lost height and eventually crashed in the Vänern Lake located 12,5 km from Karlstad Airport. Four passengers and the pilot were killed while three other passengers were rescued.
Probable cause:
The accident was caused by a double engine failure due to fuel exhaustion. This was due to the failure of the pilot to refuel the aircraft before the flight or to make a fuel stop en route. The following contributing factors were reported:
- Both engines stopped due to fuel exhaustion before the aircraft reached the destination,
- The flight was initiated with a too little amount of fuel on board,
- The pilot deviated from the current Danish regulations with regard to the prescribed minimum amount of fuel.
Final Report:

Crash of an Avro 19/1 in Karlstad: 10 killed

Date & Time: Sep 23, 1950 at 1400 LT
Type of aircraft:
Operator:
Registration:
SE-BRS
Flight Phase:
Survivors:
No
Schedule:
Karlstad – Stockholm
MSN:
1321
YOM:
1946
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
Shortly after takeoff, while climbing to a height of 200 feet, the aircraft stalled and crashed with its both engines running at full power. The aircraft was destroyed upon impact and all ten occupants were killed.
Probable cause:
It was determined that the aircraft was overloaded and that the center of gravity was outside the flight enveloppe.

Crash of a Handley Page H.P.12 in Östanå

Date & Time: Jun 30, 1920 at 1500 LT
Type of aircraft:
Operator:
Registration:
G-EAKE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kjeller – Karlstad – Stockholm - Copenhagen
MSN:
HP.22
YOM:
1919
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
At 06.50 pm the Handley Page O/400, G-EAKE, departed for the last time from Kjeller and despite the strong winds it climbed to its cruising altitude at 2,440 metres (8,000 feet). The average speed that day was 100 kmh. Donovan explained Mrs Meisterlin under the first leg of the trip how they would fly to Karlstad and Stockholm. They crossed the Norwegian-Swedish border at 7.35 pm and Arvika at 7.55 pm. The clouds were by now getting thicker and at 8.25 pm they flew above Karlstad in 1,000 metres. They looked for Hallvard Næss and his Norman Thompson N.T.2B flying boat N-13, but in vein. He was delayed. At 9 pm they cross a landscape with thousands of tree and no possibility for an emergency landing. By now it was dark and only the fire coming from the exhaust pipe lighted up the sky. At 9.50 pm they flew above the large lake Mälaren and could enjoy a beautiful view. Donovan said, “Thumbs up – Stockholm!”, when at 11.20 pm a large city was in sight. But instead of going down, the Handley Page O/400 continued in the eastern direction and ended up above the lovely archipelago north of Stockholm. They started to fly around in circles and Donovan said, “I think they have lost themselves”. It was now decided to find as soon as possible a suitable landing site and finally the crew found a field that looked good enough. They flew in low altitude above houses and fields and finally land safely in a cornfield. Sergeant Rogers thought that the field was a regular meadow, but it turned out to be a cornfield. The aircraft suffered no damages. The following day the crew together Captain Meisterlin returned to the field where sergeant Rogers the night before had landed. The aircraft looked undamaged and therefore it was decided to start that day and proceed to Stockholm and the original landing site at Häsgerstalund. The owner of the manor gathered some local workers, who would help plough a lane through the cornfield. The lane was 5 metres wide and 300 metres long. At 3 pm the “runway” was ready and crew and passengers boarded the plane after thanking the hosts for the hospitality. Rogers switched on the engines and slowly the aircraft started on its take-off. It was however soon clear that the lane was not wide enough and that the two metres high corn touched the wings making the aircraft unstable. Sergeant Rogers tried to keep the aircraft straight, failed to do so and instead he tried to lift the aircraft from the field. By now the corn had twisted itself into the undercarriage and the aircraft crashed on its noose, tipping nearly completely around. Some were thrown out of the aircraft, while others were trapped into the fuselage. After the crash Sergeant Rogers shouted to turn off the petrol in order to avoid fire. Lieutenant Gottenborg managed to get out of the aircraft and ran to Captain Meisterlin, Donovan and Sergeant Rogers in order to free them. Donovan was the one with the worst injuries. He had burns in his face and on its hands and was in great pain. He managed to get out by himself. To get out Captain Meisterlin and Sergeant Rogers from the wreckage help was needed from the local workers. Sergeant Rogers’s leg injury (from the motor cycle accident in Norway) had worsened and he and Donovan were taken by stretcher to the ambulance and driven to the hospital in Östanå. Fortunately Dr. Nicolaysen was not hurt and could offer first aid. Mrs Meisterlin and Lieutenant Gottenborg were all unhurt and the journalist Qviller had broken his arm. Finally, the aircraft was now a total wreck and was damaged beyond repair. The flight to Stockholm and København was subsequently cancelled.
Crew:
Sergeant W. Rogers, pilot
Mr. Donovan, mechanic.
Observers: Captain Wilhelm Meisterlin and Lieutenant Brynjulf Gottenborg.
Passengers:
Dr. Nicolaysen,
Mrs Astrid Meisterlin
Mr. Haakon Qviller, journalist by the Norwegian newspaper Aftenposten.

Source:
Rob Mulder - www.europeanairlines.no