Crash of a Beechcraft C90 King Air in Nantes

Date & Time: Dec 27, 1992
Type of aircraft:
Operator:
Registration:
F-GIBR
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nantes - Limoges
MSN:
LJ-734
YOM:
1977
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was engaged in an ambulance flight from Nantes to Limoges, carrying one pilot and one doctor who should embark a patient in Limoges. During the takeoff roll, just before V1 speed, the nose gear collapsed. The aircraft slid on its nose for few dozen metres before coming to rest on the runway. Both occupants escaped uninjured and the aircraft was damaged beyond repair.

Crash of a Cessna 414 Chancellor in MBS-Tri City: 3 killed

Date & Time: Mar 5, 1992 at 1504 LT
Type of aircraft:
Registration:
N69662
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
MBS-Tri-City - Chicago
MSN:
414-0621
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2057
Captain / Total hours on type:
184.00
Aircraft flight hours:
4106
Circumstances:
While loading a patient & his personal gear in the aircraft for an air ambulance flight, the aircraft tipped onto its tail. As a result, the tail bumper was forced upward into the belly of the empennage. The pilot refused the offer to have a mechanic look at the damage, and remarked 'this has happened before.' after takeoff, the pilot radioed to the tower that he had a jammed elevator, and was coming around to land. While maneuvering on a base leg, control was lost & the airplane was observed to crash with one wing perpendicular to the ground. Another airplane was in the takeoff position on the runway. The airplane was configured with a hospital litter/stretcher and oxygen bottle on the right side of the cabin. There was no record for the approval for, or installation of, the stretcher. In addition, there was no weight & balance record for the airplane with the stretcher installation. All three occupants were killed.
Probable cause:
The pilot's poor judgement in attempting flight after the airplane's fuselage was damaged during a loading operation. Factors which contributed to the accident were: the operator's failure to provide proper weight and balance data for the airplane, the pilot's failure to supervise the loading operation, and his failure to accept the services of a mechanic to inspect the damage.
Final Report:

Crash of a Swearingen SA26T Merlin II in Glenwood Springs

Date & Time: Feb 13, 1992 at 2055 LT
Type of aircraft:
Registration:
N26JB
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Grand Junction - Denver
MSN:
T26-163
YOM:
1969
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8600
Captain / Total hours on type:
750.00
Aircraft flight hours:
3988
Circumstances:
The pilot of the air ambulance feathered the right propeller after reporting 'a bit of a problem' with the right engine. He attempted to divert to the nearest suitable airport, but after receiving its latest weather report, elected to return to base. The airplane made a left turn, reentered IMC, and impacted a mountainside on a magnetic heading of 092°. The heading to the airport of intended landing was 272°. The accident occurred during a snowstorm at night. All five occupants survived and were rescued the following afternoon. Thick grease on the right engine fuel control camshaft prevented a spring from returning the 3d cam to a lower altitude position. The cam was found struck on the shaft at a position equating to an altitude of approximately 15,000 feet. The fuel flow schedule for flight idle was below specifications. In addition, shroud material was found delaminated from the left engine second stage compressor housing.
Probable cause:
Malfunction of the right engine fuel control that caused the engine to flame out, and delamination of the left engine compressor shroud. Factors were: the pilot became disoriented, the mountainous terrain, the dark night, and the weather conditions.
Final Report:

Crash of a Learjet 35A in Uberlândia

Date & Time: Mar 15, 1991 at 2107 LT
Type of aircraft:
Operator:
Registration:
PT-LIH
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberlândia
MSN:
35-433
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3850
Captain / Total hours on type:
550.00
Copilot / Total flying hours:
15175
Copilot / Total hours on type:
525
Circumstances:
The aircraft departed São Paulo-Congonhas Airport on an ambulance flight to Uberlândia, carrying two doctors and two pilots who should pick-up a patient. The copilot was pilot flying. This was his first flight on a Learjet without an instructor. This was against regulations since the copilot was not fully qualified yet and the captain was not qualified to act as an instructor. Upon arrival at Uberlândia, weather conditions were poor with a low ceiling at 100 meters (clouds 8/8), fog and an horizontal visibility less than 200 meters (below minimums weather conditions). The crew abandoned the approach and initiated a go-around procedure. Few minutes later, a second approach was also abandoned. Rather than diverting to the alternate airport, the crew attempted a third approach when the aircraft struck the ground and crashed short of runway threshold. All four occupants were seriously injured and the aircraft was destroyed.
Probable cause:
The accident was the consequence of the combination of the following factors:
- Poor flight preparation and planning,
- Poor approach planning,
- Wrong approach configuration,
- Poor crew coordination,
- Lack of visibility due to the night associated to below minimums weather conditions,
- The crew failed to initiate a go-around and to divert to the alternate airport,
- Poor crew resources management,
- Non observation of operational procedures,
- Lack of supervision on part of the captain,
- Poor operational organization on part of the operator.
Final Report:

Crash of a Cessna 441 Conquest II off Papeete: 3 killed

Date & Time: Dec 5, 1990
Type of aircraft:
Registration:
F-ODUK
Flight Type:
Survivors:
No
Schedule:
Papeete - Maupiti
MSN:
441-0270
YOM:
1983
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Papeete-Faaa Airport on an ambulance flight to Maupiti, carrying two doctors and one pilot. After takeoff, while climbing by night, the pilot informed ATC about minor problems with the engine but preferred to return for a safe landing. On final approach, the aircraft went out of control and crashed in the sea few km from the airport. All three occupants were killed. At the time of the accident, it was dark but weather conditions were excellent.

Crash of a Mitsubishi MU-2B-60 Marquise in Rapid City: 1 killed

Date & Time: Feb 9, 1990 at 1114 LT
Type of aircraft:
Registration:
N64MD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Yuma – Rapid City – Winnipeg
MSN:
747
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5985
Captain / Total hours on type:
291.00
Aircraft flight hours:
4382
Circumstances:
Witnesses reported that shortly after lift-off, the aircraft entered an unusually steep, nose high attitude, while still at low airspeed. One witness (an ATP pilot) reported the aircraft attained an altitude of approximately 75 to 100 feet and appeared to slow down and enter a VMC roll, then it crashed. Impact occurred in an inverted, nose down attitude, left of the runway. An investigation revealed that a coupling shaft (PN 865888-3) had failed in the left engine and the left prop had feathered. A metallurgical examination of the coupling showed evidence of fatigue. One pilot was killed and three other occupants were injured, one seriously.
Probable cause:
Failure of the pilot to maintain adequate airspeed (VMC), which resulted in a loss of aircraft control. A factor related to the accident was: fatigue failure of a coupling shaft in the #1 engine, which resulted in loss of power in that engine.
Final Report:

Crash of a Britten-Norman BN-2A-9 Islander in Aweil: 4 killed

Date & Time: Dec 21, 1989 at 0905 LT
Type of aircraft:
Operator:
Registration:
F-OGSM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Aweil – Khartoum
MSN:
688
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from Aweil Airport, while in initial climb, the twin engine aircraft was shot down by a SAM-7 surface-to-air missile. Out of control, it crashed 800 meters past the runway end. All four occupants were killed. The aircraft was completing an ambulance flight to Khartoum.
Probable cause:
Shot down by a SAM-7 surface-to-air missile.

Crash of a Cessna 551 Citation II/SP near Bardufoss: 4 killed

Date & Time: Nov 15, 1989 at 2302 LT
Type of aircraft:
Registration:
LN-AAE
Flight Type:
Survivors:
No
Site:
Schedule:
Tromsø - Bardufoss
MSN:
551-0245
YOM:
1980
Flight number:
AXP05
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
8920
Captain / Total hours on type:
460.00
Copilot / Total flying hours:
4067
Copilot / Total hours on type:
405
Aircraft flight hours:
3417
Aircraft flight cycles:
3389
Circumstances:
The aircraft departed Tromsø-Langnes Airport at 2248LT on an ambulance flight to Bardufoss, carrying one patient and three crew members. Four minutes later, at an altitude of 8,000 feet, the crew contacted Bardufoss control and obtained information for an ILS approach to runway 29. At 2254LT, the crew awas cleared to descend to 6,000 feet and was instructed by ATC to report once established on the ILS. At about 22:57:50 at a position about 8 NM north of the Målselv (MLV) NDB, the airspeed increased from 265 knots to 285 knots over a distance of about 5 NM. This speed was maintained up to the NDB. At 22:59:30 LN-AAE passed the MLV NDB. Instead of performing the left hand procedure turn from 174° to 122°, the crew continued a straight heading for about 30 seconds at an airspeed about 100 knots above the recommended approach speed. The aircraft was about 2 NM (4 km) south in relation to the established procedure pattern. The airplane should still have been at 6,000 feet until established on the ILS but it had descended 1,250 feet below the minimum altitude when it collided with a relatively flat mountain ridge just south of the summit of Langfjelltind (4,935 feet). The wreckage was found about 35 km east-southeast of the airport and all four occupants were killed.
Probable cause:
The accident resulted in a controlled flight into terrain after the crew failed to follow the ILS approach procedure to runway 29.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Pelée Island: 3 killed

Date & Time: Jun 24, 1989 at 2300 LT
Registration:
C-GSWC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Pelée Island - Windsor
MSN:
31-7305067
YOM:
1973
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft was dispatched at Pelée Airport to evacuate to Windsor a patient. On board were one patient, his spouse, one ambulance officer and two pilots. Shortly after a night takeoff from runway 28, while climbing, the aircraft went out of control and crashed in Lake Erie. The copilot and the patient survived while three other occupants were killed.

Crash of a Beechcraft E90 King Air in Tuba City

Date & Time: May 31, 1989 at 2215 LT
Type of aircraft:
Operator:
Registration:
N987GM
Flight Type:
Survivors:
Yes
Schedule:
Flagstaff - Tuba City
MSN:
LW-98
YOM:
1974
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4445
Captain / Total hours on type:
260.00
Aircraft flight hours:
5344
Circumstances:
The pilot stated that 15 minutes prior to arrival he notified the hospital and asked them to check the runway. As he entered downwind security advised him of animals on the runway so he circled until they called back stating it was clear. Just as the airplane was touching down, two horses began to cross the runway. The pilot attempted to go-around; however, the airplane contacted both animals and the pilot elected to abort the go-around. The left main landing gear collapsed and the airplane slid to a stop. A post crash fire ignited and was extinguished shortly thereafter. The landing was being made during dark night conditions.
Probable cause:
Ground personnel did not properly clear the runway of animals prior to reporting to the pilot that it was clear to land.
Final Report: