Crash of an Embraer EMB-500 Phenom 100 in Sedona

Date & Time: May 25, 2011 at 1550 LT
Type of aircraft:
Operator:
Registration:
N224MD
Survivors:
Yes
Schedule:
San Jose - Sedona
MSN:
500-00057
YOM:
2009
Flight number:
RSP240
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
23970
Captain / Total hours on type:
570.00
Copilot / Total flying hours:
1886
Copilot / Total hours on type:
74
Aircraft flight hours:
1052
Circumstances:
Following an uneventful flight, the flight crew briefed the arrival to the destination airport and set the calculated landing speeds. The captain and the first officer reported that during final approach, it felt like the airplane was “pushed up” as the wind shifted to a tailwind or updraft before landing near the runway number markings. Upon touchdown, the captain applied the brakes and thought that the initial braking was effective; however, he noticed the airplane was not slowing down. The captain applied maximum braking, and the airplane began to veer to the right; he was able to correct back to the runway centerline, but the airplane subsequently exited the departure end of the runway and traveled down a steep embankment. A pilot-rated passenger reported that throughout the approach to landing, he thought the airplane was high and thought that the excessive altitude continued through and into the base-to-final turn. He added that the bank angle of this turn seemed greater than 45 degrees. Recorded communication from the cockpit voice and data recorder (CVDR) revealed that during the approach to landing, the flight crew performed the landing checks, and the captain noted difficulty judging the approach. About 1 minute later, the recording revealed that the ground warning proximity system reported “five hundred” followed by a “sink rate, pull up” alert about 16 seconds later. Data from the CVDR revealed that about 23 seconds before weight-on-wheels was recorded, the airplane was at an indicated airspeed of about 124 knots and descending. The data showed that this approximate airspeed was maintained until about 3 seconds before weight-on-wheels. The recorded data further showed that the approach speed was set to 120 knots, and the landing reference speed (vREF) was set to 97 knots. Using the reported airplane configuration and the 3.5-knot headwind that was reported at the time of the approach and landing, calculations indicate that the vREF speed should have been about 101 knots indicated airspeed, which would have required a landing distance of about 3,112 feet. Utilizing the same airplane configuration and wind condition with the flight’s reported 124 knot indicated airspeed just before touchdown, the landing distance was calculated to be about 5,624 feet. The intended runway for landing was 5,132-feet long with a 1.9 percent downward slope gradient, and a 123-foot long overrun area. A postaccident examination of the airplane, including the braking system, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot misjudged the airplane’s speed during the final approach, which resulted in runway overrun.
Probable cause:
The pilots’ unstabilized approach and excessive airspeed during approach, which resulted in an insufficient landing distance to stop the airplane before overrunning the runway.
Final Report:

Crash of a Cessna 208B Grand Caravan near Quepos: 3 killed

Date & Time: Nov 29, 2001 at 1148 LT
Type of aircraft:
Operator:
Registration:
HP-1405APP
Survivors:
Yes
Site:
Schedule:
San José – Quepos – Puerto Jiménez
MSN:
208B-0788
YOM:
1999
Flight number:
LRS1625
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5000
Copilot / Total flying hours:
800
Aircraft flight hours:
1955
Circumstances:
The single engine airplane departed San José Airport on a schedule flight to Puerto Jiménez with an intermediate stop in Quepos, carrying six passengers (3 Americans, 2 Germans and one Dutch) and two pilots. While descending in clouds to Quepos Airport, the aircraft collided with trees and crashed on the slope of a wooded mountain located about 13 km from Quepos Airport. Both pilots and one passenger were killed while five other passengers were seriously injured. The aircraft was totally destroyed by impact forces.
Probable cause:
Collision with terrain after the captain failed to ensure that the vertical, horizontal and lateral separation was sufficient to fly over the mountains while descending under VMC conditions. Also the crew failed to take appropriate corrective actions to prevent the aircraft to continue the descent until it impacted ground, resulting in a controlled flight into terrain. The following contributin factors were identified:
- Momentary loss of situational awareness on the part of the flight crew,
- Inadequate supervision by the pilot-in-command,
- Non-compliance with standard operating procedures published by the operator,
- Use of flight procedures neither written down in manuals nor approved by the authority,
- Violation of safety rules,
- Non-application of visual flight rules by the flight crew,
- Shortcomings in the crew resources management,
- Adverse weather conditions.
Final Report:

Crash of a Cessna 402B in Nosara

Date & Time: Dec 20, 2000 at 1045 LT
Type of aircraft:
Operator:
Registration:
N908AB
Flight Phase:
Survivors:
Yes
Schedule:
Nosara - San José
MSN:
402B-0908
YOM:
1975
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On December 20, 2000, about 1045 mountain standard time, a Cessna 402B, N908AB, registered to Pitts Aviation, Inc., and operated by TS Aviation, as a Costa Rican air taxi flight from Nosara, Costa Rica, to San Jose, Costa Rica, crashed while making a forced landing following loss of engine power shortly after takeoff from Nosara. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed and the pilot and one passenger received serious injuries. Five passengers received minor injuries. The flight was originating at the time of the accident. Civil aviation authorities reported the flight had a loss of power in one engine during initial climb after takeoff, was unable to maintain altitude, and collided with trees. A post crash fire erupted.
Probable cause:
Engine failure for unknown reasons.

Crash of a Let L-410UVP-E in San José: 5 killed

Date & Time: Jan 15, 2000 at 1304 LT
Type of aircraft:
Registration:
YS-09-C
Flight Phase:
Survivors:
Yes
Site:
Schedule:
San José - Tortuguero
MSN:
86 16 20
YOM:
1986
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
7801
Copilot / Total flying hours:
3000
Circumstances:
After takeoff from San José-Tobías Bolaños Airport, en route to the Tortuguero National Park, while in initial climb, the aircraft stalled and crashed onto a house located in the district of Rohrmoser, about 3 km southeast of the airport. Four passengers were killed while 14 other occupants were injured, some seriously. Three people in the house, a nurse and two little girls were uninjured. Fifteen days after the accident, on January 30, the captain died from his injuries.
Probable cause:
Possible loss of longitudinal control of the aircraft in flight, due to not reaching the minimum climb speed, due to a wrong takeoff configuration as the flaps were retracted (zero position).
The following contributing factors were identified:
- Inadequate weight distribution that affected the position of the aircraft.
- The CofG was beyond the rear limit, out of the envelope.
- The crew failed to follow the pre-takeoff checklist.
- The total weight of the aircraft was above the MTOW.
- The high density altitude.
- Lack of supervision of the dispatch of the flight by the operator. (Absence of procedures).
- Self-induced pressure from the crew for an expeditious operation.
Final Report:

Crash of a Casa 212 Aviocar 200 near San José: 23 killed

Date & Time: Jan 15, 1990 at 0829 LT
Type of aircraft:
Operator:
Registration:
TI-SAB
Flight Phase:
Survivors:
No
Site:
Schedule:
San José - Palmar Norte - Golfito
MSN:
163
YOM:
1980
Flight number:
BB032
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
4822
Captain / Total hours on type:
2253.00
Aircraft flight hours:
3589
Aircraft flight cycles:
7217
Circumstances:
The twin engine aircraft departed San José-Tobías Bolaños Airport in relative good weather conditions. While climbing to an altitude of 6,000 feet, the aircraft struck the slope of the White Peak (2,438 meters high) located about 20 km southeast of the airport. The wreckage was found about 600 meters from the summit and all 23 occupants were killed. At the time of the accident, the visibility was good but some atmospheric turbulences were reported in the vicinity of the mountains.
Probable cause:
Loss of control caused by atmospheric turbulences. At the time of the accident, the crew was tired which was considered as a contributing factor as well as the fact that the operator failed to issue a valid flight safety program.

Crash of a Dassault Falcon 10 in Rancho Murieta: 3 killed

Date & Time: Oct 15, 1987 at 1528 LT
Type of aircraft:
Registration:
N121FJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rancho Murieta - San José
MSN:
192
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
8407
Captain / Total hours on type:
1200.00
Aircraft flight hours:
475
Circumstances:
The aircraft flew to the airport for a sales demonstration flight. The crew boarded the aircraft and taxied out for departure. Witnesses, including two pilots with aerobatic experience, watched the aircraft departure, make a left traffic pattern and do a low fly-by down the runway. At the departure end of the runway, the aircraft pitched up into a steep climb. At 600 feet agl, the aircraft entered a left aileron roll, which the witnesses said was 'smooth, coordinated and with the nose on the point.' At the inverted point of the roll, the roll changed from an aileron to a barrel roll. One pilot witness said that it appeared the 'crew lost it at the top' and that the crew 'held the back pressure too long at the top.' At the 270° point of the roll, the aircraft was seen to 'fall out' or 'dish out' of the roll; it recovered to wings level flight at about 100 feet agl in a very nose high attitude settling into the ground with a high vertical descent rate. No preimpact eng or control system malfunctions were found. All three occupants were killed.
Probable cause:
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
In flight loss of control by the pilot flying while performing an Intentional low level aerobatic maneuver.
Findings
Occurrence #1: loss of control - in flight
Phase of operation: maneuvering
Findings
1. (c) judgment - poor - pilot in command
2. (c) aerobatics - intentional - pilot in command
3. (f) ostentatious display - pilot in command
4. (f) altitude - inadequate - pilot in command
5. (c) flight controls - improper use of - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Cessna 340A in Orinda: 1 killed

Date & Time: Nov 13, 1982 at 1534 LT
Type of aircraft:
Registration:
N29HT
Flight Phase:
Survivors:
No
Schedule:
San Jose – Novato
MSN:
340A-0515
YOM:
1978
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
891
Aircraft flight hours:
1235
Circumstances:
After departing San Jose, CA, the pilot climbed to an altitude of 4,600 feet msl and proceeded toward Novato, CA. From 1528 to 1533 PST, radar data showed that the aircraft was level at 4,600 feet on a heading of 330° at 180 FTS ground speed. Radar info showed that the aircraft then entered a descent. During a 24 seconds period, the aircraft descended to an altitude of 4,100 feet msl and its heading changed 10° to the right. The last radar position, 12 seconds later, revealed an additional heading change of 150° to the right, accompanied by a descent to 2,300 (9000 from descent). Witnesses saw the aircraft descending at high speed in a right turn with the engines at high power. Just prior to impact, the right bank angle and nose low attitude increased. The aircraft crashed in a steep nose down, right wing low, attitude. No preimpact, mechanical malfunction or failure was found. No autopsy was made, only a gross exam of the pilot's fragmented body was possible. Before departing San Jose, the pilot had remarked that he was bothered by a bad cold. The pilot, sole on board, was killed.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: cruise - normal
Findings
1. (c) reason for occurrence undetermined
2. Physical impairment(other organic problem) - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Boeing 737-293 in Santa Ana

Date & Time: Feb 17, 1981 at 1735 LT
Type of aircraft:
Operator:
Registration:
N468AC
Survivors:
Yes
Schedule:
San Jose - Santa Ana
MSN:
20334/232
YOM:
1970
Flight number:
OC336
Crew on board:
5
Crew fatalities:
Pax on board:
105
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
11000.00
Copilot / Total flying hours:
10000
Copilot / Total hours on type:
28
Aircraft flight hours:
27566
Circumstances:
At 1644 PST Flight 336 took off from San Jose for a flight to Santa Ana. 48 Minutes later, the crew received a clearance for a visual approach to runway 19R. While Flight 336 approached, the controller cleared Air California Flight 931 for a runway 19R takeoff. When recognizing the hazard, the controller ordered Flight 336 to abort the landing and go-around and Flight 931 to abort the takeoff. Flight 931 rejected its takeoff, but Flight 336 landed with the gear retracted. The 737 left the runway surface at 900 feet past the threshold and skidded another 1,170 feet before coming to rest 115 feet to the right of the centreline. The aircraft lost its both engines and came to rest, broken in two. All 110 occupants were evacuated, four of them were injured.
Probable cause:
The captain’s failure to immediately initiate a go-around when instructed to do so by the tower’s air traffic controller and his subsequent failure to correctly execute the specified go-around procedure which resulted in the retraction of the landing gear after the aircraft touched down on the runway.
Final Report:

Crash of a Douglas C-47B-50-DK off Honolulu: 2 killed

Date & Time: Jul 20, 1979 at 1930 LT
Registration:
N63250
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Jose - Honolulu
MSN:
17062/34329
YOM:
1945
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Circumstances:
While approaching Honolulu on a ferry flight from San jose, California, the crew declared an emergency via an auxiliary emergency system that all communication and navigation systems failed. Few minutes later, the airplane crashed into the ocean off Honolulu. SAR operations were initiated but eventually abandoned few days later as no trace of the aircraft nor the two crew members was found.
Probable cause:
Double engine failure in flight following a fuel exhaustion. The following contributing factors were reported:
- The crew became lost/disoriented,
- Failure of the communications and navigations equipment,
- Failure of the Loran receiver,
- Communications failure,
- Failure of both engines,
- Forced landing off airport on water,
- Aircraft not recovered,
- Pilot reported HF radio and Loran inoperative,
- Lost,
- No fuel.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in San José

Date & Time: Apr 11, 1978 at 2042 LT
Type of aircraft:
Operator:
Registration:
N97JA
Flight Type:
Survivors:
Yes
Schedule:
Long Beach - San José
MSN:
447
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
24.00
Aircraft flight hours:
1226
Circumstances:
On final approach to San José-Reid-Hillview Airport, both engines failed. The airplane lost height, struck power cables and crashed. The pilot was seriously injured and the aircraft was destroyed.
Probable cause:
Engine failure on final approach and subsequent collision with wires due to fuel starvation. The following contributing factors were reported:
- Mismanagement of fuel,
- Aircraft equipped with ferry tanks.
Final Report: