Ambulance

Flight Type:

Survivors:

Yes

Site:

Nagurskoye (Franz Josef Archipelago)

Location:

Arkhangelsk oblast

Country:

Russia

Region:

Asia

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew was completing a medevac flight to Nagurskoye on behalf of the Soviet Border Guards. On final approach to the ice strip located on Alexandra Land, Franz Josef archipelago, the crew encountered poor weather conditions when the aircraft was caught by a wind shear, came down so hard that the nose gear punched the fuselage. There were no casualties but the aircraft was written off. The wreckage was still there at N80.80316 E47.73037 by April 2012, mostly covered by snow.

Crash of a Cessna 402C in Bundaberg: 4 killed

Date & Time: Jun 21, 1987 at 0318 LT

Type of aircraft:

Cessna 402

Operator:

Registration:

VH-WBQ

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Yes

Site:

Rockwell Grand Commander 690

Schedule:

Bundaberg - Brisbane

MSN:

402C-0627

YOM:

1982

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The flight had been arranged to transport a critically injured patient to hospital in Brisbane. The pilot evidently experienced some difficulty in starting one of the engines. However, witnesses reported that the engines sounded normal as the aircraft commenced moving from the parking area. At 0310 hours the pilot contacted Brisbane Flight Service Unit and reported that the aircraft was taxying. He advised that he was in a hurry, and indicated that he would provide details of the flight after takeoff. Two minutes later he advised that takeoff was being commenced from Runway 14. No further transmissions were received from the aircraft. The aircraft was seen to become airborne and shortly afterwards enter a fog bank. Other witnesses subsequently reported hearing the sounds of an impact. The investigation revealed that the aircraft had collided with a tree 800 metres beyond the aerodrome boundary, while tracking about 10 degrees to the right of the extended centreline of the runway. It had then continued on the same heading until striking the ground 177 metres beyond the initial impact point. The wreckage was almost totally consumed by fire.

Probable cause:

The extensive fire damage hampered the investigation of the accident. The surviving passenger believed that the aircraft was on fire before the collision with the tree. No other evidence of an in-flight fire could be obtained, and it was considered possible that the survivor's recall of the accident sequence had been affected by the impact and the fire. Such discrepancies in recall are not uncommon among accident survivors. The elevator trim control jack was found to be in the full nose-down position, but it was not possible to establish whether the trim was in this position prior to impact. Such a pre-impact position could indicate either a runaway electric trim situation or that, in his hurry to depart, the pilot had not correctly set the trim for takeoff. The aircraft was known to have had an intermittent fault in the engine fire warning system. The fault apparently caused the fire warning light to illuminate, and the fire bell to sound, usually just after the aircraft became airborne. The pilot was aware of this fault. It was considered possible that, if the fault occurred on this occasion as the aircraft entered the fog shortly after liftoff, the pilot's attention may have been focussed temporarily on the task of cancelling the warnings. During this time he would not have been monitoring the primary flight attitude indicator, and would have had no external visual references. It was also possible that, if for some reason the pilot was not monitoring his flight instruments as the aircraft entered the fog, he suffered a form of spatial disorientation known as the somatogravic illusion. This illusion has been identified as a major factor in many similar accidents following night takeoffs. As an aircraft accelerates, the combination of the forces of acceleration and gravity induce a sensation that the aircraft is pitching nose-up. The typical reaction of the pilot is to counter this apparent pitch by gently applying forward elevator control, which can result in the aircraft descending into the ground. In this particular case, the pilot would probably have been more susceptible to disorientating effects, because he was suffering from a bronchial or influenzal infection. Although all of the above were possible explanations for the accident, there was insufficient evidence available to form a firm conclusion. The precise cause of the accident remains undetermined.
It is considered that some of the following factors may have been relevant to the development of the accident
1. The pilot was making a hurried DEPARTURE. It is possible that he did not correctly set the elevator trim and/or the engines may not have reached normal operating temperatures before the takeoff was commenced.
2. Shortly after liftoff the aircraft entered a fog bank, which would have deprived the pilot of external visual references.
3. The aircraft had a defective engine fire warning system. Had the system activated it may have distracted the pilot at a critical stage of flight.
4. The aircraft might have suffered an electric elevator trim malfunction, or an internal fire, leading to loss of control of the aircraft.
5. The pilot may have experienced the somatogravic illusion and inadvertently flown the aircraft into the ground. The chances of such an illusion occurring would have been increased because the pilot was evidently suffering from an infection.

Final Report:

Crash of a Rockwell Grand Commander 690 in Bridgeport: 2 killed

Date & Time: Jun 21, 1987 at 0133 LT

Type of aircraft:

Operator:

Registration:

N662DM

Flight Phase:

Flight Type:

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Reno - Bridgeport

MSN:

690-11015

YOM:

1972

Location:

Bridgeport-Bryant Field

California

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

9521

Captain / Total hours on type:

34.00

Aircraft flight hours:

5234

Circumstances:

The flight conditions for the air ambulance trip consisted of a clear, moonless, dark night and the destination airport was in a mountain valley with the only ground reference lights the town adjacent to the airport. Witnesses saw the aircraft overfly the town and airport at pattern altitude then head out over the lake north of the airport. About 1 mile from the runway, the aircraft was seen to suddenly pitch up, roll inverted and dive straight down into the lake (Bridgeport Reservoir). The aircraft was heading away from the only ground reference lights and was over a reflective body of water near the base turn point when the accident occurred. Witnesses heard increased eng/prop noise before impact. Wreckage revealed evidence of power at impact. The shifts for the pilots in the operation consisted of 4 days on, 2 days off, with alternating day and night shifts. The pilot was on the 4th night of the current shift cycle and was also giving flight instruction during the days. Both occupants, a pilot and a nurse, were killed.

Probable cause:

Occurrence #1: loss of control - in flight
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
1. (f) light condition - dark night
2. (f) visual lookout - inadequate - pilot in command
3. (c) flight controls - inadvertent use - pilot in command
4. (c) proper altitude - not maintained - pilot in command
5. (c) visual/aural perception - pilot in command
6. (c) spatial disorientation - pilot in command
7. (f) fatigue (circadian rhythm) - pilot in command
8. (f) fatigue (flight and ground schedule) - pilot in command
9. (f) insuff standards/requirements, operation/operator - company/operator mgmt
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Findings
10. (f) descent - uncontrolled - pilot in command

Final Report:

Crash of a Learjet 24A in Vail: 3 killed

Date & Time: Mar 27, 1987 at 2045 LT

Type of aircraft:

Learjet 24

Operator:

Registration:

N31SK

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Denver - Vail

MSN:

24-118

YOM:

1966

Location:

Vail

Colorado

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

19275

Captain / Total hours on type:

2000.00

Aircraft flight hours:

8432

Circumstances:

After refueling in Denver, the medical evacuation flight was diverted from Aspen to Eagle to enplane the patient. IFR flight to Eagle was uneventful and radar service was terminated after the controller cleared the flight for the lDA-A approach to the Eagle Airport which shows a 239° inbound course. The last radio contact occurred when the crew replied 'we're 8 to 10 out and it's clear ahead' to Eagle radio in answer to a request for a base report. The flight collided with an 8,022 foot msl mountaintop bearing 298°, 3.88 miles from the airport while in the approach configuration. The safety board believes the flight was circling to land on runway 07, and the dark night prevented required visual lookout to avoid terrain obstructions. The Jeppesen approach charts used by the flightcrew did not accurately depict terrain obstructions within the 5-mile radius of the airport as stipulated in their legend. The safety board believes this could have mislead the flightcrew. All three occupants were killed.

Probable cause:

Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - vfr pattern - base leg/base to final
Findings
1. (f) terrain condition - mountainous/hilly
2. (f) preflight planning/preparation - inadequate - pilot in command
3. (f) lack of familiarity with geographic area - pilot in command
4. (f) light condition - dark night
5. Visual lookout - not possible - pilot in command
6. (f) approach charts - inaccurate
7. (c) planned approach - improper - pilot in command
8. (c) proper altitude - not maintained - pilot in command
9. (f) minimum descent altitude - disregarded - pilot in command

Final Report:

Crash of a Cessna 441 Conquest in Flagstaff: 2 killed

Date & Time: Feb 20, 1987 at 1845 LT

Type of aircraft:

Cessna 441 Conquest

Operator:

Registration:

N6858S

Flight Phase:

Flight Type:

Survivors:

Site:

Plain, Valley

Schedule:

Phoenix - Flagstaff

MSN:

441-0253

YOM:

1982

Location:

Flagstaff

Arizona

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2311

Captain / Total hours on type:

24.00

Aircraft flight hours:

3349

Circumstances:

The aircraft was on an emergency medical service (ems/medevac) flight with a pilot and a flight nurse aboard to transport a maternity patient from Flagstaff to Phoenix. During a night arrival, the pilot began a VOR-A approach in IMC, then he reported a problem with his avionics and elected to make a missed approach. During the missed approach, he said that he 'lost' an inverter, then reported the gyros were inoperative. Radar vectors were being provided when he stated 'we have big trouble here.' Soon thereafter, radar and radio contacts were lost and the aircraft crashed approximately 7 miles southeast of the airport. During impact, the aircraft made a deep crater and was demolished. No preimpact engine or airframe failure was found. An investigation revealed the #2 (copilot's) attitude indicator was inoperative on the previous flight. A discrepancy report was taken to the avionics department, but the requested entry was not made in the aircraft form-4. The pilot took off before corrective action was taken. The operations manual requested 1,000 hours multi-engine time as pic and training by esignated cfi's. The pilot had approximately 837 hours multi-engine time, recorded 9 training flights in N6858S with non-designated instructors, completed a part 135 flight check on 2/17/88. Both occupants were killed.

Probable cause:

Occurrence #1: airframe/component/system failure/malfunction
Phase of operation: approach
Findings
1. Maintenance, recordkeeping - improper
2. Procedures/directives - not followed
3. (f) inadequate surveillance of operation - company/operator mgmt
4. (c) electrical system - undetermined
5. Electrical system, inverter - inoperative
6. Flight/nav instruments, attitude indicator - inoperative
----------
Occurrence #2: loss of control - in flight
Phase of operation: approach
Findings
7. (f) light condition - dark night
8. (f) weather condition - low ceiling
9. (f) weather condition - snow
10. (c) aircraft handling - not maintained - pilot in command
11. (c) spatial disorientation - pilot in command
12. (f) lack of total experience in type of aircraft - pilot in command
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: descent - uncontrolled

Final Report:

Crash of a Cessna 402A in Melbourne: 6 killed

Date & Time: Sep 3, 1986

Type of aircraft:

Cessna 402

Operator:

Peninsula Airways

Registration:

VH-RED

Flight Phase:

Takeoff (climb)

Flight Type:

Survivors:

Site:

Schedule:

Melbourne - Leongatha

MSN:

402A-0130

YOM:

1969

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The flight was intended to return patients to their home area following medical treatment in Melbourne. After an apparently normal take-off, the aircraft ceased climbing at about 100 feet above ground level. In response to a query from the Tower, the pilot advised that the left engine had failed, that he was feathering the propeller and would return for landing. The aircraft was seen to be deviating to the left, towards a large array of power lines. These lines extend from about 40 feet to 90 feet above the ground, and as the aircraft converged with the array it was probably below the height of the upper wires. The aircraft then suddenly veered to the left and subsequently struck the ground in a steep nose-down attitude. A fire broke out on impact and destroyed much of the wreckage. The final manoeuvre performed by the aircraft was typical of that which occurs when one engine of a twin-engine aircraft is producing considerably less power than the other, and airspeed is reduced to below that required to maintain directional control. The pilot had reported that the left engine had failed, and the loss of control as described by witnesses was consistent with a reduction of power from this engine, combined with low airspeed.

Probable cause:

The investigation of the accident was hampered by the extent of the fire damage. However, an extensive technical examination did not reveal any evidence of a defect or malfunction with either the engines, the various systems or the airframe which might have contributed to the accident. Although the pilot had indicated that he was feathering the left propeller, it was determined that the propeller was not feathered at the time of the accident. It was not possible to establish if the pilot had subsequently elected not to initiate feathering action, or whether such action was initiated too late for it to be completed before impact with the ground. The reason for the loss of performance reported by the pilot could not be established. It is likely that while the aircraft was being manoeuvred to avoid the power lines and return for a landing, the airspeed decayed to below the minimum required to enable adequate control of the aircraft to be maintained. At the point where control of the aircraft was lost, there was insufficient height available for the pilot to effect recovery. The reason continued flight was attempted, rather than a controlled forced landing in open areas prior to the power lines, could not be determined.

Final Report:

Crash of a PZL-Mielec AN-2 near Nazimovo: 4 killed

Date & Time: Nov 16, 1985

Type of aircraft:

PZL-Mielec AN-2

Operator:

Registration:

CCCP-07877

Flight Phase:

Flight

Flight Type:

Survivors:

Site:

Plain, Valley

MSN:

1G170-36

YOM:

1976

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

The crew received a special permission for an ambulance flight as the weather conditions were poor and the visibility was below minimums. En route, the crew encountered snow falls and icing conditions when the aircraft crashed in the region of Nazimovo. As the airplane failed to arrive at destination, SAR operations were initiated but eventually abandoned after few days as no trace of the aircraft nor the four occupant was found. The wreckage was found on 18 June 1986 in an isolated area. It was determined that the aircraft struck tree tops in a 30° nose-down angle and crashed in a wooded area.

Crash of a Learjet 24D near Juneau: 4 killed

Date & Time: Oct 22, 1985 at 2043 LT

Type of aircraft:

Learjet 24

Operator:

Registration:

N456JA

Flight Phase:

Flight Type:

Survivors:

Site:

Mountains

Schedule:

Anchorage – Juneau

MSN:

24-265

YOM:

1973

Location:

Juneau

Alaska

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

5578

Captain / Total hours on type:

547.00

Aircraft flight hours:

6303

Circumstances:

During arrival to pick up a medevac patient, the flight was cleared for an LDA-1 runway 08 approach via the Asort transition. Thus, the pilot should have continued southeast on J-541 toward the SSR vortac and intercepted the localizer (loc) at Asort; then track inbound on the loc (062°), using I-JDL frequency 109.9 MHz (frequency for loc and co-located DME). After Asort, minimum altitude was 6,500 feet to Dibol intersection, 5,100 feet to Lynns intersection and 3,400 feet to the faf at Barlo intersection. DME from I-JDL to the intersections was: 18.2, 13.5 and 8 miles. DME from SSR (south of loc track) to the intersections was 11.2, 12.7 and approximately 16 miles. Flight reported Asort inbound while descending thru approximately 9,500 feet. Last radio call was 30 seconds later while descending thru 8,200 feet, 14 miles west of Dibol. Approximately 4 miles west of Dibol, aircraft impacted mountain side at 3,500 feet msl. No preimpact mechanical malfunction was found. There was evidence that both nav's were tuned to 109.9 MHz, but DME control head was inadvertently left in 'hold' position (locking DME to SSR rather than I-JDLl) and crew began a premature descent. Juneau weather was in part: 600 feet scattered, 3,000 feet overcast, 7 miles visibility. Pilot-in-command was currently flying both Learjet and DHC-7. All four occupants, two pilots and two doctors, were killed.

Probable cause:

Occurrence #1: in flight collision with terrain/water
Phase of operation: approach - iaf to faf/outer marker (ifr)
Findings
1. (f) comm/nav equipment,distance measuring eqpt(dme) - not switched
2. (c) flight/navigation instrument(s) - improper use of
3. (f) habit interference - pilot in command
4. (c) became lost/disoriented - inadvertent - pilot in command
5. (c) descent - premature
6. (c) unsafe/hazardous condition - not identified - copilot/second pilot
7. (f) light condition - dark night
8. (f) weather condition - clouds
9. (f) terrain condition - mountainous/hilly
10. (c) proper altitude - not maintained - pilot in command
11. (f) terrain condition - rising

Final Report:

Crash of a Beechcraft 65-B80 Queen Air in Lanseria: 5 killed

Date & Time: Aug 31, 1985

Type of aircraft:

Beechcraft 80 Queen Air

Operator:

Sunair

Registration:

9J-AAW

Flight Phase:

Flight Type:

Survivors:

Site: