Crash of a Beechcraft 200C Super King Air in Mount Gambier: 1 killed

Date & Time: Dec 10, 2001 at 2336 LT
Operator:
Registration:
VH-FMN
Flight Type:
Survivors:
Yes
Schedule:
Adelaide - Mount Gambier - Adelaide
MSN:
BL-47
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
13730
Captain / Total hours on type:
372.00
Aircraft flight hours:
10907
Circumstances:
The Raytheon Beech 200C Super King Air, registered VH-FMN, departed Adelaide at 2240 hours Central Summer Time (CSuT) under the Instrument Flight Rules for Mount Gambier, South Australia. The ambulance aircraft was being positioned from Adelaide to Mount Gambier to transport a patient from Mount Gambier to Sydney for a medical procedure, for which time constraints applied. The pilot intended to refuel the aircraft at Mount Gambier. The planned flight time to Mount Gambier was 52 minutes. On board were the pilot and one medical crewmember. The medical crewmember was seated in a rear-facing seat behind the pilot. On departure from Adelaide, the pilot climbed the aircraft to an altitude of 21,000 ft above mean sea level for the flight to Mount Gambier. At approximately 2308, the pilot requested and received from Air Traffic Services (ATS) the latest weather report for Mount Gambier aerodrome, including the altimeter sub-scale pressure reading of 1012 millibars. At approximately 2312, the pilot commenced descent to Mount Gambier. At approximately 2324, the aircraft descended through about 8,200 ft and below ATS radar coverage. At approximately 2326, the pilot made a radio transmission on the Mount Gambier Mandatory Broadcast Zone (MBZ) frequency advising that the aircraft was 26 NM north, inbound, had left 5,000 ft on descent and was estimating the Mount Gambier circuit at 2335. At about 2327, the pilot started a series of radio transmissions to activate the Mount Gambier aerodrome pilot activated lighting (PAL).2 At approximately 2329, the pilot made a radio transmission advising that the aircraft was 19 NM north and maintaining 4,000 ft. About 3 minutes later, he made another series of transmissions to activate the Mount Gambier PAL. At approximately 2333, the pilot reported to ATS that he was in the circuit at Mount Gambier and would report after landing. Witnesses located in the vicinity of the aircraft’s flight path reported that the aircraft was flying lower than normal for aircraft arriving from the northwest. At approximately 2336 (56 minutes after departure), the aircraft impacted the ground at a position 3.1 NM from the threshold of runway (RWY) 18. The pilot sustained fatal injuries and the medical crewmember sustained serious injuries, but egressed unaided.
Probable cause:
The following factors were identified:
- Dark night conditions existed in the area surrounding the approach path of the aircraft.
- For reasons which could not be ascertained, the pilot did not comply with the requirements of the published instrument approach procedures.
- The aircraft was flown at an altitude insufficient to ensure terrain clearance.
Final Report:

Crash of a Learjet 25B in Ciudad Victoria

Date & Time: Oct 26, 2001 at 1930 LT
Type of aircraft:
Operator:
Registration:
N715MH
Flight Type:
Survivors:
Yes
Schedule:
Houston – Matamoros – Ciudad Victoria
MSN:
25-132
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On October 26, 2001, at 1930 central daylight time, a Learjet 25B transport category airplane, N715MH, was substantially damaged when both main landing gears collapsed during the landing touchdown at Ciudad Victoria, State of Tamaulipas, in the Republic of Mexico. The captain, first officer, 2 medical attendants, and 2 passengers aboard the airplane were not injured. The airplane was owned and operated by American Jet International of Houston, Texas. The air ambulance flight originated from the Houston Hobby Airport approximately 1800, and made an intermediate stop at the Matamoros Airport (MMMA) to clear Mexican customs. Night visual meteorological prevailed for the flight, for which and instrument flight rules flight plan was filed.

Crash of a Swearingen SA226TC Metro II in Shamattawa: 2 killed

Date & Time: Oct 11, 2001 at 2333 LT
Type of aircraft:
Operator:
Registration:
C-GYPA
Flight Type:
Survivors:
Yes
Schedule:
Gods Lake Narrows – Shamattawa
MSN:
TC-250
YOM:
1978
Flight number:
PAG962
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3100
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
900
Circumstances:
Perimeter Airlines Flight PAG962, a Fairchild SA226TC (Metroliner), with two pilots and a flight nurse on board, departed Gods Lake Narrows, Manitoba, at approximately 2300 central daylight time, on a MEDEVAC flight to Shamattawa. Approaching Shamattawa, the crew began a descent to the 100 nautical mile minimum safe altitude of 2300 feet above sea level (asl) and, when clear of an overcast cloud layer at about 3000 feet asl, attempted a night, visual approach to Runway 01. The aircraft was too high and too fast on final approach and the crew elected to carry out a missed approach. Approximately 30 seconds after the power was increased, at 2333, the aircraft flew into trees slightly to the left of the runway centreline and about 2600 feet from the departure end of Runway 01. The aircraft was equipped with a cockpit voice recorder (CVR) that indicated the crew were in control of the aircraft; they did not express any concern prior to impact. The aircraft broke apart along a wreckage trail of about 850 feet. Only the cabin aft of the cockpit retained some structural integrity. The captain and first officer were fatally injured on impact. The flight nurse was seriously injured but was able to exit the wreckage of the cabin. A post-crash fire was confined to the wings which had separated from the cabin and cockpit wreckage.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was flown into terrain during an overshoot because the required climb angle was not set and maintained to ensure a positive rate of climb.
2. During the go-around, conditions were present for somatogravic illusion, which most likely led to the captain losing situational awareness.
3. The first officer did not monitor the aircraft instruments during a critical stage of flight; it is possible that he was affected by somatogravic illusion and/or distracted by the non-directional
beacon to the extent that he lost situational awareness.
Other Findings:
1. The absence of approach aids likely decreased the crew=s ability to fly an approach from which a landing could be executed safely.
2. The company standard operating procedures (SOPs) did not define how positive rate is to be determined.
Final Report:

Crash of a PZL-Mielec AN-2T in Kobyay

Date & Time: Apr 23, 2001 at 1745 LT
Type of aircraft:
Operator:
Registration:
RA-01122
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pokrovsk – Magan – Kobyay – Sangar
MSN:
1G238-04
YOM:
1990
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
2135
Aircraft flight cycles:
3112
Circumstances:
The aircraft departed Pokrovsk on an ambulance flight to Sangar with intermediate stops in Magan and Kobyay. On approach to Kobyay Airport, the aircraft was too high and its speed was excessive. Rather than initiating a go-around procedure, the captain continued the approach and landed 375 metres pas the runway threshold (the runway length is 600 metres). Unable to stop within the remaining distance, the aircraft overran, collided with various obstacles and came to rest 50 metres further. The crew did not report the incident to the company and decided to take off few minutes later. After liftoff, the aircraft was unable to gain sufficient speed and height. It struck trees and crashed in a snow covered terrain, bursting into flames. All 13 occupants were injured, among them five seriously. The aircraft was destroyed by fire.
Probable cause:
It was determined that the captain was intoxicated at the time of the accident and that he started the mission from Pokrovsk already drunk. He took the decision to take off from Kobyay Airstrip despite the propeller blades have been damaged during the previous overrun.

Crash of a Cessna 500 Citation I in Sault Sainte Marie

Date & Time: Feb 26, 2001 at 1030 LT
Type of aircraft:
Operator:
Registration:
N234UM
Flight Type:
Survivors:
Yes
Schedule:
Detroit – Sault Sainte Marie
MSN:
500-0105
YOM:
1973
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2770
Captain / Total hours on type:
1410.00
Copilot / Total flying hours:
3142
Copilot / Total hours on type:
300
Aircraft flight hours:
8329
Circumstances:
The captain said that he flew the VOR approach to runway 32. At 2,500 feet, the captain said that they were out of the clouds and initiated a visual straight-in approach. After aligning the airplane with the runway, the captain said he noticed that there was contamination on the runway, "maybe compacted snow or maybe ice with fresh snow over it." The captain briefed that they would perform a go-around if by midfield they were not decelerating adequately. The captain said that they touched down within the first third of the runway. Close to midfield the airplane fishtailed. Past midfield, the captain called a go-around. The first officer said that the captain added power and he retracted the airbrakes. The first officer exclaimed, "There is not enough runway! I braced myself as the aircraft went into the snow." The first officer said that at about 2 miles out from the runway, the unicom called and said that braking action was nil. A Notice to Airman, in effect at the time of the accident for the airport stated, "icy runway, nil braking."
Probable cause:
The pilot exceeding the available runway distance during landing and the pilot's delay in executing a go-around. Factors relating to the accident were, the pilots improper in-flight planning/decision, the pilot disregarding the NOTAMS for the airport, the pilot failing to properly consider the warning given by the Unicom operator regarding the icy runway and nil braking action, the icy runway, and the drop-off/descending embankment.
Final Report:

Crash of a Learjet 35 in Schenectady

Date & Time: Jan 4, 2001 at 1547 LT
Type of aircraft:
Registration:
N435JL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Schenectady – New York-LaGuardia
MSN:
35-018
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2570
Captain / Total hours on type:
1065.00
Copilot / Total flying hours:
1600
Copilot / Total hours on type:
497
Aircraft flight hours:
16302
Circumstances:
The captain stated that prior to departure the flight controls were tested, with no abnormalities noted, and the takeoff trim was set to the "middle of the takeoff range," without referring to any available pitch trim charts. During the takeoff roll, the pilot attempted to rotate the airplane twice, and then aborted the takeoff halfway down the 4,840 foot long runway, because the controls "didn't feel right." The airplane traveled off the departure end of the runway and through a fence, and came to rest near a road. The pilot reported no particular malfunction with the airplane. Examination of the airplane revealed that the horizontal stabilizer was positioned at -4.6 degrees, the maximum nose down limit within the takeoff range. The horizontal stabilizer trim and elevator controls were checked, and moved freely through their full ranges of travel. According to the AFM TAKEOFF TRIM C.G. FUNCTION chart, a horizontal stabilizer trim setting of -7.2 was appropriate with the calculated C.G. of 20% MAC. Additionally, Learjet certification testing data stated that the pull force required at a trim setting of -6.0 degrees, the "middle of the takeoff range", was 33 pounds. With the trim set at the full nose down position (-1.7 degrees), 132 pounds of force was required.
Probable cause:
The pilot's improper trim setting, which resulted in a runway overrun and impact with a fence.
Final Report:

Crash of a Cessna 340A in Selma: 1 killed

Date & Time: Nov 6, 2000 at 0400 LT
Type of aircraft:
Operator:
Registration:
N12273
Flight Type:
Survivors:
Yes
Schedule:
Paso Robles – Selma
MSN:
340A-1536
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19000
Captain / Total hours on type:
2000.00
Aircraft flight hours:
4915
Circumstances:
The airline transport rated pilot was returning an organ transplant nurse passenger to an uncontrolled, no facilities airport, with ground fog present about 0400 in the morning. The pilot had obtained two abbreviated preflight weather briefings while waiting for his passenger, and prior to departing at 0235. According to witnesses he attempted to land twice on runway 28, then he made an approach and attempted a landing on runway 10. Witnesses reported that the airport was engulfed in ground fog at the time of the approaches. They said that you could see straight up but not horizontally. The airplane collided with grape vineyard poles and canal/wash berms, about 250 feet short of the runway 10 displaced threshold. Approach charts for two airports with instrument approaches within 20 miles were found lying on the instrument panel glare shield. The passenger's car was parked at the uncontrolled airport.
Probable cause:
The pilot's improper decision to attempt a visual approach and landing in instrument meteorological conditions and his failure to follow instrument flight rules procedures.
Final Report:

Crash of a Beechcraft B200C Super King near Kulu-Bhuntar: 5 killed

Date & Time: Jul 29, 2000 at 1332 LT
Registration:
VT-EIE
Flight Type:
Survivors:
No
Site:
Schedule:
New Delhi – Kulu-Bhuntar
MSN:
BL-63
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
8340
Captain / Total hours on type:
776.00
Copilot / Total flying hours:
526
Aircraft flight hours:
6243
Aircraft flight cycles:
5646
Circumstances:
The twin engine aircraft departed New Delhi-Indira Gandhi Airport on an ambulance flight to Kulu-Bhuntar, carrying three doctors and two pilots. While descending to Kulu-Bhuntar Airport in IMC conditions, the crew failed to realize his altitude was insufficient when the aircraft struck the slope of a mountain located 20 km from the destination airport. The aircraft was destroyed and all five occupants were killed.
Probable cause:
The pilot descended below minimum sector altitude in Instrument Meteorological Condition in hilly area.
Contributing factors were:
1. ATC Chandigarh contributed to the accident by permitting IFR flight to descend below minimum sector altitude.
2. Inadequate Supervision, Lack of Safety culture and poor pre-flight planning. Factor: Pilot: Non-adherence to standard operating procedure.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Liverpool: 5 killed

Date & Time: Jun 14, 2000 at 0950 LT
Operator:
Registration:
G-BMBC
Flight Type:
Survivors:
No
Schedule:
Douglas - Liverpool
MSN:
31-7952172
YOM:
1979
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
18000
Circumstances:
The aircraft, operated by an Air Operator's Certificate holder, was engaged on an air ambulance operation from Ronaldsway in the Isle of Man to Liverpool. Having flown under VFR on a direct track to the Seaforth dock area of Liverpool the pilot flew by visual reference along the northern coast of the Mersey Estuary to carry out a visual approach to Runway 09 at Liverpool. During the turn on to the final approach, when approximately 0.8 nm from the threshold and 0.38 nm south of the extended centreline, the aircraft flew into the sea and disappeared. All five occupants were killed.
Probable cause:
The investigation concluded that the pilot lost control of the aircraft at a late stage of the approach due either to disorientation, distraction, incapacitation, or a combination of these conditions.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Eagle Pass

Date & Time: Oct 18, 1998 at 0600 LT
Operator:
Registration:
N19MH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Eagle Pass - San Antonio
MSN:
421C-1008
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2095
Captain / Total hours on type:
120.00
Aircraft flight hours:
4071
Circumstances:
During takeoff climb, the twin-engine airplane encountered a strong downdraft and impacted trees and terrain. The pilot reported that while taxiing to the runway, he scanned the sky with the monochrome weather radar, which was set at the 40-mile range. 'No weather was shown behind the runway and a cell was shown 15 miles from the runway.' The takeoff roll was 'uneventful,' and the airplane was rotated at 95 knots. Climb out was accomplished at 110 knots, the engines were at maximum power, the propellers at maximum RPM, and the manifold pressure was indicating maximum. A 10-degree turn towards the Cotulla VOR was being made when at 1,500 feet msl, a sharp descent was felt with the VSI indicating an 800 ft/min rate of descent. The wings were leveled and the airspeed was slowed to 85 knots. 'The rate of descent slowed to 400 ft/min and then finally to 300 ft/min until impact...' The airplane was destroyed by fire that erupted on impact. A review of doppler weather radar images showed thunderstorms in the vicinity of the airport.
Probable cause:
A downdraft, which exceeded the aircraft's climb performance. A factor was the thunderstorms in the vicinity of the airport.
Final Report: