Crash of a Learjet 24B in Orlando

Date & Time: May 23, 1998 at 0330 LT
Type of aircraft:
Registration:
N100DL
Flight Type:
Survivors:
Yes
Schedule:
Miami - Orlando
MSN:
24-201
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18395
Captain / Total hours on type:
318.00
Aircraft flight hours:
8138
Circumstances:
During landing roll, the airplanes normal braking system failed as a result of hydraulic fluid leak(s). At the pilot's request, deployment of the drag chute and application of the emergency braking system was performed by the first officer. According to the first officer, application of the emergency brakes caused the airplane to yaw. The first officer then pulled up on the emergency brakes handle followed by re-application of braking pressure. This action took place several times during the landing roll. Gates' Learjet Flight Training Manual (Page 105) states, 'In using the emergency brake lever, slow steady downward pressure is required. Each time the lever is allowed to return upward to the normal position, nitrogen is evacuated overboard. Brace your hand so you will not allow the lever to move up and down inadvertently on a bumpy runway.' The airplane overran the end of the runway and collided with the Instrument Landing System back course antennae.
Probable cause:
The first officer's failure to perform proper emergency braking procedures.
Final Report:

Crash of a Beechcraft A100 King Air in Sioux Lookout

Date & Time: Dec 7, 1997 at 1505 LT
Type of aircraft:
Operator:
Registration:
C-GILM
Flight Type:
Survivors:
Yes
Schedule:
Winnipeg – Sioux Lookout
MSN:
B-124
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Voyageur Airways Beechcraft A100 aircraft, C-GILM, was on a flight from Winnipeg International Airport Winnipeg International Airport, MB (YWG) to Sioux Lookout Airport, ON (YXL). The crew of two pilots and two paramedics had completed a medevac flight and were returning to Sioux Lookout without a patient on board. The weather was reported to be: wind 060 degrees at two knots, visibility three statute miles in freezing drizzle, and ceiling overcast at 400 feet AGL. The First Officer was at the controls as they attempted two full NDB approaches for runway 34, each of which resulted in a missed approach. The captain then took control of the aircraft and conducted a full NDB approach for runway 34. On final approach, the crew had the runway in sight and the aircraft was lined up, but the aircraft was high on the approach. The captain called for full flap and pushed the props up to help slow the aircraft down. The aircraft developed a high rate of descent that was not fully countered before the aircraft contacted the runway firmly with the left main landing gear. The aircraft was taxied part way to the company ramp before the aircraft began pulling to the left very noticeably. The scissors had failed and the main wheels were turned slightly off-line. While conducting a heavy-landing inspection, company maintenance and operational personnel determined that in addition to the damage to the scissors for the left main landing gear, the rear spar of the left wing had failed in the vicinity of a pass-through hole for the flap actuator. The damage is reported to be overload in nature and consistent with the effects of landing hard on the left main wheel. During the approaches, the aircraft was above cloud during the penetration turns and was only in cloud during the final approach phases. A small amount of ice accumulated on the aircraft while in cloud (about 1/8th to 1/4 inch on the spinner remained after landing) but the de-ice equipment was working and was used.

Crash of an Embraer EMB-121A Xingu in Chapecó: 7 killed

Date & Time: Oct 1, 1997 at 2145 LT
Type of aircraft:
Operator:
Registration:
PP-EHJ
Flight Type:
Survivors:
No
Schedule:
Porto Alegre – Chapecó
MSN:
121-027
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
5500
Captain / Total hours on type:
288.00
Copilot / Total flying hours:
4254
Copilot / Total hours on type:
320
Circumstances:
The aircraft was completing an ambulance flight from Porto Alegre to Chapecó, carrying five doctors and two pilots. On approach to Chapecó-Serafim Enoss Bertaso Airport by night, the crew encountered poor weather conditions. On final, the aircraft struck the ground and crashed 2,5 km short of runway 29. A passenger was seriously injured while six other occupants were killed. Few hours later, the only survivor died from his injuries.
Probable cause:
The crew continued the approach at an unsafe altitude for unknown reasons. At the time of the accident, weather conditions were poor, which was considered as a contributing factor as well as the lack of crew training.
Final Report:

Crash of a Cessna 414 Chancellor on Mt Beech Knob: 2 killed

Date & Time: Nov 26, 1996 at 1208 LT
Type of aircraft:
Registration:
N73CP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Summersville – Waynesboro
MSN:
414-0505
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8000
Captain / Total hours on type:
2720.00
Aircraft flight hours:
9358
Circumstances:
Shortly after takeoff, the pilot contacted Charleston Approach Control to pick up his IFR clearance to the destination. The controller instructed the pilot to maintain VFR and he then attempted to coordinate with Washington Center for the clearance. The controller subsequently was unable to establish radar contact with the flight and he also lost radio contact with the pilot. The aircraft collided with the upslope of high terrain in weather conditions comprised of fog, sleet, and snow. The accident site was about 14 miles from the departure point. Toxicological testing of the pilot revealed benzoylecgonine.
Probable cause:
The pilot's inadequate inflight decision which resulted in VFR flight into instrument meteorological conditions and his failure to maintain adequate terrain clearance which resulted in an inflight collision with terrain. The low ceiling was a factor.
Final Report:

Crash of a Mitsubishi MU-2B-36 Marquise in Scottsdale

Date & Time: Jul 20, 1996 at 0857 LT
Type of aircraft:
Operator:
Registration:
N999FA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Scottsdale - Phoenix
MSN:
676
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4559
Captain / Total hours on type:
81.00
Aircraft flight hours:
8878
Circumstances:
The right engine lost power after an uncontained engine failure during the initial takeoff climb. The airplane would not climb and the pilot was forced to land. The pilot selected a street for a forced landing area. The pilot landed gear up while maneuvering to avoid hitting street light poles and automobiles. After touchdown, the airplane slid into a block wall. A fire erupted as a result of a post impact fuel leak in the left wing. The airplane's engines were examined at the manufacturer's facilities. The right engine exhibited evidence of an uncontained separation of the second stage turbine rotor disk. Examination of the disk fragments revealed a low cycle fatigue fracture mode. The fatigue initiated from multiple areas at and adjacent to the inside diameter bore surface near the aft side of the disk. According to the engine manufacturer, the multiple indication areas were associated with uninspectable size porosity and the primary carbides in the cast material. There were no material or casting defects detected on any of the fractures through the wheel.
Probable cause:
Aan uncontained failure of the second stage turbine wheel due to fatigue. Factors were: obstructions in the forced landing area and the inability of the airplane to climb after the turbine wheel failure.
Final Report:

Crash of a Britten-Norman BN-2A-26 Islander in Tingwall: 1 killed

Date & Time: May 19, 1996 at 2336 LT
Type of aircraft:
Operator:
Registration:
G-BEDZ
Flight Type:
Survivors:
Yes
Schedule:
Inverness - Tingwall
MSN:
544
YOM:
1977
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3879
Captain / Total hours on type:
305.00
Aircraft flight hours:
14700
Aircraft flight cycles:
39900
Circumstances:
At 2300 hrs the two Tingwall fire attendants opened the airstripfor the returning flight. The airstrip lights were turned on and the fire appliance made ready. The firemen reported that,sometime later, the pilot radioed Tingwall asking for the wind speed and direction. This was passed as 090° to 120°/20 kt. One of the firemen also reported that at the time there was veryfine drizzle but the visibility was good. Analysis of recorded radar data from the radar head at Sumburgh confirmed that the aircraft routed over Lerwick and then flew north turning west inland over Kebister Ness. The doctor reported that, on approaching Lerwick he could see the lights of the town and the visibility was good enough for him to identify his house. The aircraft then turned southwards to join downwind right hand for Runway 02. The doctor stated that there were not many lights on the ground to the north of the airstrip but some to the south in the vicinity of Veensgarth. He also stated that the ride at this stage was moderately turbulent. At the end of the downwind leg the aircraft banked 'sharply' to the right to position on finals. It had, however, been blown through the centreline by the gusty easterly wind and was to the left of the required approach. The doctor confirmed that although the aircraft appeared to be at the correct height for its position he could see that when they were lined up the airfield lights were to the right of the windscreen. The pilot, unable to complete the approach, carried out a go-around to the left of the runway,climbed to 550 feet and turned right to enter the downwind leg again. The doctor reported that the engines sounded normal throughout this manoeuvre and the runway lights were clearly visible again as the aircraft became established on the downwind track. Several witnesses saw the aircraft fly downwind and turn onto the final approach. One witness, positioned on higher ground to the east of the runway threshold, stated that the aircraft flew downwind along the line of the houses at Veensgarth and 'asit turned it descended all the while'. Radar information shows that for this second attempt the pilot extended the downwind legby approximately 800 metres before turning towards the airfield. The rapid turn onto finals was described by the doctor as being very steep but without the increase in 'g' that he would have expected for such an steep angle of bank. The nurse described the sensation as 'the aircraft dropped, with my cheeks and whole body being forced upwards'. Throughout the turn the pilot was seen by the passengers to be generally looking to the right, presumably for the airfield. Seconds later the aircraft hit the ground. After the impact the nurse found herself still in her seat with the aircraft in an upright position. She was relatively uninjured and soon released her seatbelt, released her trapped right foot and struggled clear of the wreckage through the open right rear aircraft window. She ran around the tail section to the doctor and released debris from around his head. Unable to move him because of his injuries, she ran to a nearby house to summon the emergency services. The doctor, although seriously injured, remained conscious throughout and managed to clamber clear of the aircraft to lie on the round some ten feet from the wreckage. The pilot had received fatal injuries at impact.
Final Report:

Crash of a Beechcraft E90 King Air in Flagstaff: 3 killed

Date & Time: Jan 31, 1996 at 1305 LT
Type of aircraft:
Operator:
Registration:
N300SP
Flight Type:
Survivors:
No
Site:
Schedule:
Flagstaff - Phoenix
MSN:
LW-166
YOM:
1976
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
10700
Captain / Total hours on type:
613.00
Aircraft flight hours:
5952
Circumstances:
The pilot and 2 nurses departed IFR to transport a patient from another location. During the initial climb, the pilot observed a gear unsafe light. He requested clearance to an area of VFR conditions to address the gear problem. Subsequently, the gear was manually extended with safe gear indications. The flight department requested that the pilot return to base. The pilot obtained an IFR clearance to return for an ILS approach. After handoff to the tower, he was requested to report the FAF inbound after an eastbound procedure turn. That was the last communication from the pilot. Subsequently, the aircraft crashed on the southeast side of Humphreys Peak at an elevation of about 10,500 feet and about 10 miles west of the final approach course. Wreckage was scattered along a heading of 230 degrees. There was evidence that the airplane was in a steep descent when it crashed. Radar data revealed an outbound track west of the published course and no procedure turn. The weather was IMC with light snow and rain. Moderate to severe turbulence was forecast and confirmed by other pilots. The winds at 10,000 feet were forecast to be 50 knots out of the southwest. Moderate turbulence and light rime ice had been reported along the ILS approach course before to the accident time.
Probable cause:
Failure of the pilot to follow prescribed IFR procedures and his failure to maintain control of the aircraft. Factors relating to the accident were: the adverse weather conditions with icing and turbulence.
Final Report:

Crash of a Cessna 401A in Spokane: 3 killed

Date & Time: Jan 8, 1996 at 1907 LT
Type of aircraft:
Registration:
N117AC
Flight Type:
Survivors:
Yes
Schedule:
Pasco - Spokane
MSN:
401A-0040
YOM:
1969
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
3500
Captain / Total hours on type:
70.00
Aircraft flight hours:
5800
Circumstances:
The pilot received abbreviated weather briefing for emergency medical service (EMS)/air ambulance flight. Before flight, he expressed anxiety about possible low visibility for landing and timely transport of dying patient. During ILS runway 03 approach (rwy 03 approach), the aircraft remained well above the glide slope until close to the middle marker; aircraft's speed decreased from 153 to 100 kts, while vertical speed increased from 711 feet/min to about 1,250 feet/min descent. About 1 mile from runway and 500 feet agl (in fog), the aircraft abruptly turned left of localizer course and gradually descended with no distress call from pilot. The aircraft hit a pole, then flew into a building and burned. Low ceiling, fog and dark night conditions prevailed. Pilot (recent ex military helicopter pilot) had logged/reported 3,500 hours of flight time and about 150 hours in multiengine airplanes, but there was evidence he lacked experience with actual instrument approaches in fixed wing aircraft; he had difficulty with instrument flying during recent training and FAA check flights. No preimpact mechanical problem was found with aircraft/engines. No ILS anomalies were found. Flight nurse was using cellular phone, but no evidence was found of interference with aircraft's navigational system. Visibility and ceiling at destination were less than forecast at time of pilot's preflight weather briefing. Paramedic was only survivor.
Probable cause:
Failure of the pilot to follow proper IFR procedures, by failing to maintain proper alignment with the localizer course during the ILS approach and/or by failing to follow the proper missed approach procedure. Factors relating to the accident were: darkness; adverse weather conditions; and pressure on the pilot to complete the EMS flight, due to the circumstances and conditions that prevailed.
Final Report:

Crash of a Piper PA-31-325 Navajo in Wollaston Lake

Date & Time: Nov 25, 1995 at 2325 LT
Type of aircraft:
Registration:
C-GOLM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Wollaston Lake – La Ronge
MSN:
31-7712050
YOM:
1977
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4920
Captain / Total hours on type:
450.00
Aircraft flight hours:
7056
Circumstances:
The Eagle Air Services Piper PA-31-325 Navajo, C-GOLM, departed runway 34 at Wollaston Lake, Saskatchewan, at 2325 central standard time (CST), on a medical evacuation (MEDEVAC) flight to La Ronge. The flight was arranged by the Wollaston nursing station to transport a patient to a hospital in La Ronge. The patient was accompanied on the flight by her mother and a nurse from the nursing station. The aircraft was observed to climb at an unusually shallow angle after take-off, and, when efforts by company personnel to reach the pilot by radio were unsuccessful, a ground search was commenced. The aircraft was found about five minutes after the accident, located on the ice- and snow-covered surface of Wollaston Lake, about 0.75 nautical miles (nm) from the departure end of the runway, and about 1.3 nm from the point of commencement of the take-off roll. The pilot and the patient suffered serious injuries. The other two occupants sustained minor injuries. The accident occurred during the hours of darkness at latitude 58°6.98'N, longitude 103°10.79'W, at an elevation of 1,300 feet above sea level (asl). The temperature was about -25°/C.
Probable cause:
After take-off, the left propeller was likely on its start locks, which, as the airspeed increased, allowed the propeller to overspeed. The pilot was unable to resolve the situation in time to prevent the aircraft from striking the surface of Wollaston Lake. Contributing to the severity of the patient's injuries were the inadequate restraint provided by the stretcher and its restraining strap, the lack of standards regarding stretchers used in aircraft, and the lack of standards as to the operation of MEDEVAC flights.
Final Report:

Crash of a Learjet 36A in Zarzaitine

Date & Time: Sep 26, 1995 at 2300 LT
Type of aircraft:
Operator:
Registration:
HB-VFS
Flight Type:
Survivors:
Yes
Schedule:
Geneva – Zarzaitine – Accra – Zarzaitine – Geneva – London – Geneva
MSN:
36-042
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Geneva-Cointrin on an ambulance flight to Accra with an intermediate stop in Zarzaitine, carrying two doctors and two pilots. The goal of the mission was to repatriate a patient to London via Geneva after a crew change. While descending to runway 05 at Zarzaitine-In Amenas Airport by night, the crew was informed by ATC that runway 23 was in service. The crew followed a circuit and started the descent to runway 23. On final approach in low visibility (dark night), the crew failed to realize his altitude was insufficient when the aircraft struck the top of a sand dune. The undercarriage were torn off and the aircraft crash landed 3 km short of runway, bursting into flames. Both doctors escaped uninjured, the female copilot was slightly injured and the captain was seriously injured. The aircraft was totally destroyed.
Probable cause:
Controlled flight into terrain during a visual approach completed in limited visibility due to the dark night.