Crash of a Beechcraft 65-80 Queen Air in Manila: 13 killed

Date & Time: Dec 10, 2011 at 1415 LT
Type of aircraft:
Registration:
RP-C824
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Manila - San Jose
MSN:
LD-21
YOM:
1962
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
On December 10, 2011, BE-65-80QA (Queen Air) with Registry RP-C824 took off from RWY 13, Manila Domestic Airport on/or about 0610 UTC (1410H) southbound for San Jose, Mindoro. There were three (3) persons on board, the PIC and two (2) other persons; one was seated at the right-hand cockpit seat and the other one at the passenger seat. After airborne, the ATC gave instructions to the pilot o turn right and report five (5) miles out. After performing the right turn, the pilot requested for a reland which was duly acknowledged but the ATC with instructions to cross behind traffic on short final Rwy 06 (a perpendicular international runway) and to confirm if experiencing difficulty. However, there was no more response from the pilot. From a level flight southward at about 200 feet AGL, three (3) loud sputtering/burst sounds coming from the aircraft were heard (by people on the ground) then the aircraft was observed making a left turn that progressed into a steep bank and roll-over on a dive. After about one complete roll on a dive the aircraft hit ground at point of impact (Coordinates 14.48848 N 121.025811 E), a confined area beside a creek surrounded by shaties where several people were in a huddle. Upon impact, the aircraft exploded and fire immediately spread to surrounding shanties and a nearby elementary school building. The aircraft was almost burned into ashes and several shanties were severely burned by post-crash fire. A total of thirteen (13) persons were fatality injured composed of: the 3 aircraft occupants who died due to non survivable impact and charred by post-crash fire, and ten (10) other persons on the ground, all residents at vicinity of impact point, incurred non-fatal injuries and were rushed to a nearby hospital for medical treatment. About 20 houses near the impact point were completely burnt and the adjacent Elementary School building was severely affected by fire.
Probable cause:
The Aircraft Accident Investigation and Inquiry Board determined that the probable cause of this accident was:
- Immediate Cause:
(1) Pilot’s Lack of event proficiency in emergency procedures for one (1) engine in-operative condition after-off. Pilot Error (Human Factor)
While a one engine in-operative condition during take-off after V1 is a survivable emergency event during training, the pilot failed to effectively maintain aircraft control the aircraft due to inadequate event proficiency.
- Contributing Cause:
(1) Left engine failure during take-off after V1. (Material Factor)
The left engine failed due to oil starvation as indicated by the severely burnt item 7 crankshaft assembly and frozen connecting rods 5 & 6. This triggered the series of events that led to the failure of the pilot to manage a supposedly survivable emergency event.
- Underlying Causes:
(1) Inadequate Pilot Training for Emergency Procedure. Human Factor
Emergency event such as this (one engine inoperative event – twin engine aircraft) was not actually or properly performed (discussed only) in actual training flights/check-ride and neither provided with corresponding psycho-motor training on a simulator. Hence, pilot’s motor skill/judgment recall was not effective (not free-flowing) during actual emergency event.
(2) Inadequate engine overhaul capability of AMO. Human Factor
There was no document to prove that engine parts scheduled to be overhauled aboard were complied with or included in the overhaul activity. The presence unauthorized welding spot in the left-hand engine per teardown inspection report manifested substandard overhaul activity.
(3) Inadequate regulatory oversight (airworthiness inspection) on the overhaul activity of the AMO (on engine overhaul). Human Factor
The airworthiness inspection on this major maintenance activity (engine overhaul) failed to ensure integrity and quality of replacement parts and work done (presence of welding spots).
(4) Unnecessary Deviation by ATC from the AIP provision on Runway 13 Standard VFR Departure Southbound.
The initiative of the AY+TC for an early right turn southbound after airborne was not in accord with the standard departure in the AIP which provides the safest corridor for takeoff and the ample time to stabilize aircraft parameters in case of a one engine inoperative emergency event for a successful re-land or controlled emergency landing.
Final Report:

Crash of a Beechcraft 300 Super King Air in Concord

Date & Time: Oct 19, 2000 at 1538 LT
Registration:
N398DE
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Concord - San Jose
MSN:
FA-109
YOM:
1986
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10868
Captain / Total hours on type:
35.00
Aircraft flight hours:
3801
Circumstances:
The twin turboprop airplane overran the runway, impacted two fences, and an occupied automobile after the airline transport pilot attempted to abort a takeoff. The pilot performed a rolling takeoff and was paying close attention to balancing the engine power and keeping runway centerline alignment. As the airplane accelerated, the pilot set the power above 80 percent and began an instrument scan. He then noted the airspeed indicator was reading zero with the needle resting on the peg. After a moment's hesitation, the pilot attempted to abort the takeoff by reducing the power levers to flight idle, and subsequently over the gate to ground fine. He reported to the FAA that he did not place the power controls into the reverse position. Air traffic controllers reported they observed the airplane with its nose wheel off of the ground approximately 3/4 of the way down the 4,602-foot long runway. The aircraft's left and right pitot/static systems were examined and tested after the accident, and no anomalies were noted. The pilot obtained verbal training on rejected/aborted takeoffs for the accident airplane. He obtained his type rating and 14 CFR 135 check-out in the accident airplane approximately 1 month prior to the accident. The pilot had accumulated a total of 10,867.5 hours of flight time, of which 34.7 hours were accumulated in the accident aircraft make and model. The pilot reported his total pilot-in-command flight time in the accident aircraft make and model as 20 hours, all of which were accumulated within the preceding 30 days of the accident. Examination of the airplane, the flight instruments and the pitot/static system found no explanation for the pilot reported lack of airspeed reading. The brakes were found to be fully functional. Review of the performance charts for the airplane disclosed that for the weight and ambient conditions of the takeoff, the airplane required 4,100 feet for an
accelerate-stop distance; the runway was 4,602 feet long.
Probable cause:
The pilot's delayed decision to abort the takeoff and his failure to utilize the propeller's reverse pitch function.
Final Report:

Crash of a Cessna 414 Chancellor in Orland

Date & Time: May 21, 1999 at 1725 LT
Type of aircraft:
Registration:
N8153Q
Flight Type:
Survivors:
Yes
Schedule:
San Jose – Redding
MSN:
414-0053
YOM:
1970
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:
480.00
Aircraft flight hours:
4471
Circumstances:
The pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidly decaying altitude, and power. During the landing roll, the airplane collided with a ditch. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synthetic polymer that is used as an agricultural soil amendment that aids in reducing soil erosion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be improperly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminates with no caps or covers for protection.
Probable cause:
A loss of engine power in both engines due to fuel contamination, which resulted from the fueling facilities improper quality control procedures.
Final Report:

Crash of a Beechcraft A100 King Air in San Jose

Date & Time: Nov 28, 1996
Type of aircraft:
Operator:
Registration:
RP-C710
Survivors:
Yes
MSN:
B-15
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at San Jose Airport, the aircraft collided with a dog. On impact, the right main gear collapsed and the aircraft came to rest on its belly. The right engine struck the ground and caught fire. All three occupants escaped uninjured while the aircraft was damaged beyond repair. The dog was killed.

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

Date & Time: Dec 23, 1995 at 0019 LT
Operator:
Registration:
N27954
Flight Type:
Survivors:
No
Site:
Schedule:
Oakland - San Jose
MSN:
31-7952062
YOM:
1979
Flight number:
AMF041
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4659
Captain / Total hours on type:
914.00
Aircraft flight hours:
9840
Aircraft flight cycles:
10966
Circumstances:
The aircraft impacted mountainous terrain in controlled flight during hours of darkness and marginal VFR conditions. The flight was being vectored for an instrument approach during the pilot's 14 CFR Part 135 instrument competency check flight. The flight was instructed by approach control to maintain VFR conditions, and was assigned a heading and altitude to fly which caused the aircraft to fly into another airspace sector below the minimum vectoring altitude (MVA). FAA Order 7110.65, Section 5-6-1, requires that if a VFR aircraft is assigned both a heading and altitude simultaneously, the altitude must be at or above the MVA. The controller did not issue a safety alert, and in an interview, said he was not concerned when the flight approached an area of higher minimum vectoring altitudes (MVA's) because the flight was VFR and 'pilots fly VFR below the MVA every day.' At the time of the accident, the controller was working six arrival sectors and experienced a surge of arriving aircraft. The approach control facility supervisor was monitoring the controller and did not detect and correct the vector below the MVA.
Probable cause:
The failure of the air traffic controller to comply with instructions contained in the Air Traffic Control Handbook, FAA Order 7110.65, which resulted in the flight being vectored at an altitude below the minimum vectoring altitude (MVA) and failure to issue a safety advisory. In addition, the controller's supervisor monitoring the controller's actions failed to detect and correct the vector below the MVA. A factor in the accident was the flightcrew's failure to maintain situational awareness of nearby terrain and failure to challenge the controller's instructions.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Orinda: 5 killed

Date & Time: Apr 3, 1988 at 1906 LT
Type of aircraft:
Registration:
N6ET
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Redding - San Jose
MSN:
31-7612012
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
6500
Circumstances:
Before the accident, witnesses observed the aircraft circling in a valley beneath a low cloud layer and below the surrounding hilltops. They estimated the ceiling was 400 feet obscured. Two witnesses said the aircraft entered clouds before it crashed. A 3rd witness, who was a pilot, said the aircraft was at a very low altitude when it approached rising/mountainous terrain; he said the aircraft then entered a steep climbing turn and stalled after making two complete turns. Impact occurred in a nose low, left wing down attitude. No preimpact mechanical problem was found. The FAA had issued the pilot a special 3rd class medical certificate after he had quintuple heart bypass surgery. He was reported to have gotten 'quite angry' before the flight, when 2 passengers were late. A pathologist believed the pilot's death may have been due to arteriosclerotic heart disease; however, this was not verified. The pilot did not have an instrument rating and no record of a preflight weather briefing was found. All five occupants were killed.
Probable cause:
Occurrence #1: in flight encounter with weather
Phase of operation: cruise
Findings
1. (f) preflight planning/preparation - inadequate - pilot in command
2. (f) terrain condition - mountainous/hilly
3. (f) weather condition - low ceiling
4. (f) weather condition - fog
5. (f) vfr flight into imc - continued - pilot in command
----------
Occurrence #2: loss of control - in flight
Phase of operation: maneuvering
Findings
6. Maneuver - initiated
7. (c) airspeed - not maintained - pilot in command
8. (c) stall - inadvertent - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Piper PA-61P Aerostar (Ted Smith 601) in San Jose: 2 killed

Date & Time: Feb 4, 1980 at 1034 LT
Operator:
Registration:
N8078J
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Jose - San Jose
MSN:
61P-0565-7963245
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2400
Captain / Total hours on type:
15.00
Circumstances:
The twin engine airplane departed San Jose Municipal Airport on a local aerial photography mission, carrying one passenger and one pilot. En route, the airplane stall, entered a spin and crashed in flames. The aircraft was totally destroyed and both occupants were killed.
Probable cause:
Stall and subsequent spin after the pilot failed to maintain flying speed. During a radar vector to ILS, the pilot reported he would be taking pictures at a slow speed.
Final Report:

Crash of a Beechcraft C-45H Expeditor in the Pacific Ocean: 1 killed

Date & Time: Nov 4, 1979 at 1529 LT
Type of aircraft:
Registration:
N145DC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Jose - Honolulu
MSN:
AF-564
YOM:
1953
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
En route from San Jose to Honolulu on a delivery flight, the pilot informed ATC about an engine failure and elected to ditch the airplane about 1,500 km northwest of Honolulu. The aircraft came to rest in water and the pilot was killed.
Probable cause:
Powerplant failure for undetermined reasons.
Final Report:

Crash of a Lockheed L-1329 JetStar 6 in Chicago: 4 killed

Date & Time: Mar 25, 1976 at 1431 LT
Type of aircraft:
Registration:
N1EM
Flight Phase:
Survivors:
No
Schedule:
Chicago - San Jose
MSN:
5077
YOM:
1966
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
12250
Captain / Total hours on type:
61.00
Circumstances:
During the takeoff roll at Chicago-Midway Airport runway 13R, the nose gear lifted off twice but the airplane failed to takeoff. Decision to abandon the takeoff procedure was taken too late. Unable to stop within the remaining distance, the airplane overran at a speed of about 60-80 knots, crossed a perimeter road, went through a fence, struck an ILS antenna and came to rest in flames against concrete blocks. The aircraft was totally destroyed and all four occupants were killed.
Probable cause:
Collision with fence posts after an aborted takeoff. The following contributing factors were reported:
- Delayed action in aborting takeoff,
- Inadequate preflight preparation,
- Lack of familiarity with aircraft,
- Ran off the end of runway,
- Pilot-in-command flew JetStar version 8 and never flew the 6 version which has 1,200 lbs less thrust than the 8 version.
Final Report:

Crash of a Douglas C-47-DL off Shelter Cove: 17 killed

Date & Time: Jun 27, 1971 at 1800 LT
Registration:
N90627
Flight Phase:
Survivors:
Yes
Schedule:
Shelter Cove – San Jose
MSN:
4642
YOM:
1942
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
17
Captain / Total flying hours:
12000
Circumstances:
After liftoff at Shelter Cove Airport, the airplane encountered difficulties to gain height. The undercarriage struck an electric transformer and the left engine struck the roof of a sewage disposal building. Shortly later, the airplane entered a left bank and crashed into the sea about 150 yards offshore. Both pilots and 15 passengers were killed while seven other occupants were seriously injured. The aircraft was destroyed.
Probable cause:
Inadequate preflight preparation on part of the flying crew who failed to remove the rudder and elevator control locks prior to takeoff.
Final Report: