Crash of a De Havilland DHC-6 Twin Otter 100 in Hyannis: 1 killed

Date & Time: Jun 18, 2008 at 1001 LT
Operator:
Registration:
N656WA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hyannis - Nantucket
MSN:
47
YOM:
1967
Flight number:
WIG6601
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3607
Captain / Total hours on type:
99.00
Aircraft flight hours:
38185
Circumstances:
The pilot contacted air traffic control and requested clearance to taxi for departure approximately an hour after the scheduled departure time. About 4 minutes later, the flight
was cleared for takeoff. A witness observed the airplane as it taxied, and found it strange that the airplane did not stop and "rev up" its engines before takeoff. Instead, the airplane taxied into the runway and proceeded with the takeoff without stopping. The airplane took off quickly, within 100 yards of beginning the takeoff roll, became airborne, and entered a steep left bank. The bank steepened, and the airplane descended and impacted the ground. Post accident examination of the wreckage revealed that the pilot's four-point restraint was not fastened and that at least a portion of the cockpit flight control lock remained installed on the control column. One of the pre-takeoff checklist items was, "Flight controls - Unlocked - Full travel." The airplane was not equipped with a control lock design, which, according to the airframe manufacturer's previously issued service bulletins, would "minimize the possibility of the aircraft becoming airborne when take off is attempted with flight control locks inadvertently installed." In 1990, Transport Canada issued an airworthiness directive to ensure mandatory compliance with the service bulletins; however, the Federal Aviation Administration did not follow with a similar airworthiness directive until after the accident.
Probable cause:
The pilot's failure to remove the flight control lock prior to takeoff. Contributing to the accident was the Federal Aviation Administration's failure to issue an airworthiness directive making the manufacturer's previously-issued flight control lock service bulletins mandatory.
Final Report:

Crash of a Learjet 35A in Kisangani

Date & Time: Jun 12, 2008 at 1245 LT
Type of aircraft:
Operator:
Registration:
D-CFAI
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kisangani – Bukavu
MSN:
35-365
YOM:
1981
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a cargo flight from Kisangani to Bukavu on behalf of the United Nations. During the takeoff roll, the crew decided to reject takeoff for unknown reasons. The aircraft deviated to the right, causing the main gear to be torn off. The aircraft then slid for few dozen metres and came to rest with its right wing severely damaged. Both pilots escaped uninjured.

Crash of an Antonov AN-32B in Goma

Date & Time: May 26, 2008 at 1500 LT
Type of aircraft:
Registration:
9Q-CMG
Flight Type:
Survivors:
Yes
Schedule:
Goma – Kalima
MSN:
32 01
YOM:
1993
Location:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Few minutes after takeoff from Goma Airport, en route to Kalima, the crew reported engine problems and was cleared to return for an emergency landing. After touchdown, control was lost. The aircraft veered off runway to the right and collided with lava blocs. The aircraft was destroyed and all five occupants were injured.

Crash of a Boeing 747-209F in Brussels

Date & Time: May 25, 2008 at 1331 LT
Type of aircraft:
Operator:
Registration:
N704CK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
New York – Brussels – Bahrain
MSN:
22299/462
YOM:
1980
Flight number:
CKS207
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
7000
Copilot / Total hours on type:
200
Aircraft flight hours:
108560
Aircraft flight cycles:
20599
Circumstances:
The flight crew arrived at Brussels the day before the accident, with a flight from Bahrain. The crew rested until the Sunday morning. The aircraft arrived at Brussels on Sunday with another crew; the two crews exchanged some information regarding the airplane. There were no mechanical problems reported. Runway 20 was in service for take-offs, while Runway 25L was mostly used for landings. The pilot performed the pre-flight inspection; he found only minor discrepancies (left inner tire check and E&E door latch down). The pre-flight briefing covered the standard departure call-outs, the runway incursion information, a discussion on the Runway 20 length, etc.. The crew also briefed about the engine failure procedures for an engine failure prior to V1, and they also briefed about an abort takeoff after V1 if there was a dangerous situation that would not allow the airplane to fly. After completing the flight documents, the crew requested an early departure, which they received. For the computation of the take-off parameters, the crew used the Kalitta Air On-board Performance System (OPS computer). The crew determined they needed the full length of the runway for take-off. The airplane taxied towards the B1 intersection for the Runway 20. After a few minutes, waiting for another airplane to land on Runway 25, they lined up on Runway 20, making a tight turn, in order to gain a few meters with respect to the usual departure position. The airplane was cleared for take-off at 11:29. The pilot pushed the throttles forward and checked the engines were stable. The Flight Engineers then set the engine power for take-off (setting “normal”, also known as “reduced thrust”). The aircraft started to accelerate. The standard call-out were made when the speed reached the determined value.
- “airspeed”
- 80 knots
- V1
A few seconds after reaching V1, the engine N°3 ingested a bird. Approximately 5 seconds after V1, the engine N°3 stalled and caused a loud “bang”, and a vibration felt in the cockpit. The pilot stated he had the feeling that the aircraft was no longer accelerating, and decided to abort the take-off. Two seconds after having heard the detonation, the thrust levers were brought back to idle, and braking action was initiated. The thrust reversers were not deployed. The FO called the tower, and notified the aircraft was going to the overrun. The pilot turned the aircraft a few degrees to the right, in order to avoid the approach lights at the end of the runway. The aircraft left the runway at a speed of approximately 72 Knots. The aircraft reached a first embankment, dropping from a height of 4 m, and broke in three parts. The aircraft came to a stop just above the top of the railroad embankment. The crew exited the airplane through the service door since the L1 door normally used was blocked due to deformation of the structure.
Probable cause:
The accident was caused by the decision to reject the takeoff 12 knots after passing V1 speed. The following factors contributed to the accident:
- Engine Nr 3 experienced a bird strike, causing it to stall. This phenomenon was accompanied by a loud bang, noticed by the crew.
- The aircraft line up at the B1 intersection although the take-off parameters were computed with the full length of the runway.
- The situational awareness of the crew,
- Less than maximum use of deceleration devices.
- Although the RESA conforms to the minimum ICAO requirement, it does not conform to the ICAO recommendation for length.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Ada

Date & Time: May 9, 2008 at 2045 LT
Type of aircraft:
Operator:
Registration:
N893FE
Flight Type:
Survivors:
Yes
Schedule:
Traverse City - Grand Rapids
MSN:
208B-0223
YOM:
1990
Flight number:
FDX7343
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5600
Captain / Total hours on type:
3450.00
Aircraft flight hours:
8625
Circumstances:
The airplane was on a visual approach to an airport when the engine stopped producing power. The pilot subsequently landed the airplane in a field, but struck trees at the edge of the field during the forced landing. Examination of the engine, engine fuel controls, and Power Analyzer and Recorder (PAR), provided evidence that the engine shut down during the flight. Further examination of engine and fuel system components from the accident airplane failed to reveal a definitive reason for the uncommanded engine shut-down.
Probable cause:
A loss of engine power for undetermined reasons.
Final Report:

Crash of a Piper PA-31T Cheyenne II in Foremost

Date & Time: Apr 25, 2008 at 1430 LT
Type of aircraft:
Operator:
Registration:
C-FRJE
Flight Type:
Survivors:
Yes
MSN:
31-7820002
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft made a wheels-up landing at Foremost Airport. The pilot, sole on board, was uninjured while the aircraft was damaged beyond repair. For unknown reasons, the landing gear had not been extended on approach.

Crash of a Swearingen SA227AC Metro III off Sydney: 1 killed

Date & Time: Apr 9, 2008 at 2327 LT
Type of aircraft:
Operator:
Registration:
VH-OZA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Sydney – Brisbane
MSN:
AC-600
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4873
Captain / Total hours on type:
175.00
Aircraft flight hours:
32339
Aircraft flight cycles:
46710
Circumstances:
On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a ‘slight technical fault’ and no other transmissions were heard from the pilot. Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured and the aircraft was destroyed. Both of the aircraft’s on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft.
Probable cause:
Contributing Safety Factors:
- It was very likely that the aircraft’s alternating current electrical power system was not energised at any time during the flight.
- It was very likely that the aircraft became airborne without a functioning primary attitude reference or autopilot that, combined with the added workload of managing the ‘slight technical fault’, led to pilot spatial disorientation and subsequent loss of control.
Other Safety Factors:
- The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual, with the result that the pilot’s competence and ultimately, safety of the operation could not be assured. [Significant safety issue].
- The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of omissions in the operator’s training and checking requirements.
- The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.
Final Report:

Crash of an Embraer EMB-820C Carajá in Lençóis: 2 killed

Date & Time: Mar 31, 2008 at 0630 LT
Operator:
Registration:
PT-VCI
Flight Type:
Survivors:
No
Schedule:
Salvador – Lençóis
MSN:
820-144
YOM:
1986
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
25000
Captain / Total hours on type:
1769.00
Copilot / Total flying hours:
750
Copilot / Total hours on type:
195
Aircraft flight hours:
7293
Circumstances:
The twin engine aircraft departed Salvador Airport at 0525LT on a cargo flight to Lençóis, carrying two pilots and a load of bank documents. On final approach to Lençóis Airport, the crew encountered limited visibility due to marginal weather conditions. The captain decided to continue the approach and completed a turn to the left when the aircraft crashed 2 km from the runway threshold, bursting into flames. The aircraft was totally destroyed and both pilots were killed.
Probable cause:
The decision of the captain to continue the approach under VFR mode in IMC conditions to an airport that was not suitable for IFR operations. The following contributing factors were identified:
- The lack of ground references may have contributed to the commander's spatial disorientation,
- Although the weather conditions made it impossible to land under VFR conditions, the captain insisted on landing, neglecting IFR procedures,
- The captain ignored the copilot's advice and continued with the approach procedure,
- The captain put the aircraft in an attitude that caused it to stall,
- Poor judgment on part of the captain,
- Despite the implementation of a CRM program, the operator was unable to identify that the captain was violating the published procedures.
Final Report:

Ground fire of a Transall C-160NG in Wamena

Date & Time: Mar 6, 2008 at 0920 LT
Type of aircraft:
Operator:
Registration:
PK-VTQ
Flight Type:
Survivors:
Yes
Schedule:
Jayapura – Wamena
MSN:
F235
YOM:
1985
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 6 March 2008, a Transall C-160 aircraft, registered PK-VTQ, operated by PT. Manunggal Air, was on an unscheduled freight flight from Sentani Airport, Jayapura, to Wamena Airport, Papua. There were seven people on board; two pilots, two engineers, and three flight officers. The pilots reported that the approach and landing were normal. However, they told the investigators that both Beta lights did not illuminate during the landing roll, so they could not use reverse thrust. They reported that they used maximum brakes to slow the aircraft, and rolled through to the end of runway 15. During the 180-degree right turn at the end of the runway, they felt the left brakes grabbing, and had to use increased thrust on the left engine to assist the turn. After completing the turn, the pilots backtracked the aircraft towards taxiway “E”, about 450 meters from the departure end of runway 15. The air traffic controller informed the Transall crew that heavy smoke was coming from the left main wheels, and that they should proceed to taxiway “E” and stop on the taxiway. Before the aircraft entered taxiway “E”, the controller activated the crash alarm. The pilots stopped the aircraft on taxiway “E”, and the occupants disembarked and attempted to extinguish the wheel-bay fire with a hand held extinguisher. The airport rescue fire fighting service (RFFS) arrived at the aircraft 10 minutes after the aircraft came to a stop on taxiway “E”. It took a further 5 minutes to commence applying foam. The attempts to extinguish the fire were unsuccessful, and the fire destroyed the aircraft and its cargo of fuel in drums. Investigators found molten metal on the runway along the left wheel track for about 16 meters, about 100 meters from taxiway “E”, between taxiway “E” and the departure end of runway 15. There was also molten metal along the left wheel track on taxiway “E”.
Probable cause:
The aircraft’s left main wheels’ brakes overheated during the landing roll and a fire commenced in the brake assembly of one or more of the left main landing gear wheels. The evidence indicated that a brake cylinder and/or hydraulic line may have failed. It is likely that brake system hydraulic fluid under pressure, was the propellant that fed the fire. There was no Emergency Response Plan at Wamena. The RFFS delay in applying fire suppressant resulted in the fire engulfing the aircraft.
Final Report:

Crash of an Ilyushin II-76TD in Kandahar

Date & Time: Feb 14, 2008
Type of aircraft:
Registration:
UN-76020
Flight Type:
Survivors:
Yes
MSN:
00434 50493
YOM:
1984
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Kandahar Airport, the engine n°1 exploded and caught fire. The crew was able to stop the aircraft and to evacuate the cabin. The left wing and wing root suffered fire damage.