Crash of a Swearingen SA227AC Metro III near Stratford: 2 killed

Date & Time: May 3, 2005 at 2214 LT
Type of aircraft:
Operator:
Registration:
ZK-POA
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Auckland – Blenheim
MSN:
AC-551B
YOM:
1983
Flight number:
AWO023
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6500
Captain / Total hours on type:
2750.00
Copilot / Total flying hours:
2345
Copilot / Total hours on type:
70
Aircraft flight hours:
29010
Aircraft flight cycles:
29443
Circumstances:
The crew requested engine start at 2128 and Post 23 taxied for runway 23R at about 2132. The flight data recorder (FDR) showed that during the taxi a left turn through about 320° was made in 17 seconds. Post 23 departed at about 2136 with the first officer (FO) the pilot flying (PF). The planned cruise level was flight level (FL) 180 but the cockpit voice recorder (CVR) showed that in order to get above turbulence encountered at that level the crew requested, and were cleared by air traffic control (ATC), to cruise at FL220. The autopilot was engaged for the climb and cruise. There were 2 CVR references to the crew’s use of the de-icing system to remove trace or light icing from the wings. CVR comments also indicated that stars were visible, and that the aircraft’s weather radar was serviceable. At 2159 ATC cleared Post 23 to track from near New Plymouth very high frequency (VHF) omni-directional radio range (VOR) direct to Tory VOR at the northeast end of the Marlborough Sounds, and at 2206 ATC transferred Post 23 to Christchurch Control. The CVR recorded normal crew interaction and aircraft operation, except that climb power remained set for about 15 minutes after reaching cruise level in order to make up some of the delay caused by the late departure. At about 2212:28, after power was reduced to a cruise setting and the cruise checks had been completed, the captain said, “We’ll just open the crossflow again…sit on left ball and trim it accordingly”. The only aircraft component referred to as “crossflow”, and operable by a flight deck switch or control, was the fuel crossflow valve between the left and right wing tanks. The captain repeated the instruction 5 times in a period of 19 seconds, by telling the FO to, “Step on the left pedal, and just trim it to take the pressure off” and “Get the ball out to the right as far as you can …and just trim it”. The FO sought confirmation of the procedure and said, “I was being a bit cautious” to which the captain replied, “Don’t be cautious mate, it’ll do it good”. Nine seconds later the FO asked, “How’s that?”. The Captain replied, “That’s good – should come right – hopefully it’s coming right.” There was no other comment at any time from either pilot about the success or otherwise of the fuel transfer. During this time, the repeated aural alert of automatic horizontal stabiliser movement sounded for a period of 27 seconds, as the stabiliser re-trimmed the aircraft as it slowed from the higher speed reached during cruise at climb power. Forty-seven seconds after opening the crossflow, the captain said, “Doesn’t like that one mate… you’d better grab it.” Within one second there was the aural alert “Bank angle”, followed by a chime tone, probably the selected altitude deviation warning. Both pilots exclaimed surprise. After a further 23 seconds the captain asked the FO to confirm that the autopilot was off, but it was unclear from the CVR whether the captain had taken control of the aircraft at that point. The FO confirmed that the autopilot was off just before the recording ended at 2213:41. The bank angle alert was heard a total of 7 times on the CVR before the end of the recording. During the last 25 seconds of radar data recorded by ATC, Post 23 lost 2000 ft altitude and the track turned left through more than 180°. Radar data from Post 23 ceased at 2213:45 when the aircraft was descending through FL199 about 1700 metres (m) southeast of the accident area. Commencing at 2213:58, the ATC controller called Post 23 three times, without response. He then initiated the uncertainty phase of search and rescue for the flight. The operator had a flight-following system that displayed the same ATC radar data from Airways Corporation of New Zealand (ACNZ). The operator’s dispatcher noticed that the data for Post 23 had ceased and, after discussing this with ACNZ, he advised the operator’s management. There were many witnesses to the accident who reported noticing a very loud and unusual noise. Some, familiar with the sound of aircraft cruising overhead on the New Plymouth – Wellington air route, thought the noise was an aircraft engine but described it as “high-revving” or “roaring”. Witnesses A were located about 3 kilometres (km) south of the southernmost part of the track of Post 23 as recorded by ATC radar, and about 6 km south of the accident site. They described going outside to identify the cause of an intense noise. As they looked northeast and upwards about 45°, they saw an orange-yellow light descending through broken cloud layers at high speed. A “big burst” and 3 or 4 separate fireballs were observed “just above the horizon” about 5 km away. No explosion was heard. The biggest fireball lasted the longest time and was above the others. The night was dark and it had been drizzling. Witness B, almost 7 km to the northeast of the accident site, observed light and dark cloud patterns moving towards the northwest. She thought the moon caused the light variation; however moonrise was almost 3 hours later. This witness also first observed a fireball below the cloud at an elevation of about 6°. She described it as “a big bright circle” followed by 2 smaller fireballs that fell slowly. No explosion was heard. Witness C, who was less than 1000 m from the aircraft’s diving flight path, described seeing the nose section falling after an explosion “like a real big ball of fire”. The wings were then seen falling after a smaller fireball that was followed by a third small fireball. The witness said it was a still night, with no rain at that time, and the fireballs were observed below the lowest cloud. The fireballs illuminated falling wreckage and cargo. Witness D, also less than 1000 m from the accident site, described parts of the aircraft falling, illuminated by the fireball. Witnesses generally agreed that the first and biggest fireball was round and orange, and then shrank away. Descriptions of the smaller fireballs varied, but were usually of a more persistent, streaming flame that fell very steeply or straight down. A large number of emergency service members and onlookers converged on the accident area. Those who got within about 1000 m of the scene reported a strong smell of fuel. The first item of wreckage was located at about 2315. The main wreckage field was on hilly farmland 7 km northeast of Stratford at an elevation of approximately 700 ft.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The flight crew was appropriately licensed and rated for the aircraft, and qualified for the flight.
- The captain was experienced on the type and the operation, and approved as a line training captain, while the FO was recently trained and not very experienced on the type.
- The aircraft had a valid Certificate of Airworthiness and records indicated that it had been maintained in accordance with its airworthiness requirements. There were no relevant deferred
maintenance items prior to dispatch of the accident flight.
- Although the aircraft had been refuelled in one tank only, it probably took off with the fuel balanced within limits.
- Some fuel imbalance led the captain to decide to carry out further fuel balancing while the aircraft was in cruising flight.
- The captain’s instructions to the FO while carrying out fuel balancing resulted in the aircraft being flown at a large sideslip angle by the use of the rudder trim control while the autopilot was engaged.
- The FO’s reluctance to challenge the captain’s instruction may have been due to his inexperience and underdeveloped CRM skills.
- The autopilot probably disengaged automatically because a servo reached its torque limit, allowing the aircraft to roll and dive abruptly as a result of the applied rudder trim.
- The crew was unable to recover control from the ensuing spiral dive before airspeed and g limits were grossly exceeded, resulting in the structural failure and in-flight break-up of the aircraft.
- The in-flight fire which occurred was a result of the break-up, and not a precursor to it.
- The applied rudder trim probably contributed to the crew’s inability to recover control of the aircraft.
- The crew’s other control inputs to recover from the spiral dive were not optimal, and contributed to the structural failure of the aircraft.
- The flying conditions of a dark night with cloud cover below probably hindered the crew’s early perception of the developing upset.
- The AFM limitation on use of the autopilot above 20 000 ft should have led to the crew disconnecting it when climbing the aircraft above that altitude.
- The crew’s non-observance of this autopilot limitation probably did not affect its performance, or its automatic disengagement.
- If the aircraft had been manually flown during the fuel-balancing manoeuvre, the upset would probably have not occurred.
- The operator should detail the in-flight fuel balancing procedure as a written SOP for its Metro aircraft operation.
- The AFM for the SA 226/227 family of aircraft should include a limitation and warning that the autopilot must be disconnected while in-flight fuel balancing is done, and should include a procedure for in-flight fuel balancing.
Final Report:

Crash of an Antonov AN-12BP in Kabul

Date & Time: Apr 25, 2005
Type of aircraft:
Operator:
Registration:
UN-11003
Flight Type:
Survivors:
Yes
Schedule:
Dubai – Kabul
MSN:
5 3 430 04
YOM:
1965
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Kabul Airport, following an uneventful cargo flight from Dubai, the aircraft became uncontrollable. It veered off runway to the left and came to rest. A small fire erupted near the undercarriage and was quickly extinguished. All six crew members were rescued but slightly injured. The aircraft was damaged beyond repair.
Probable cause:
Loss of control after a tyre burst shortly after touchdown.

Crash of a Piper PA-31-350 Navajo Chieftain in Comox: 2 killed

Date & Time: Apr 22, 2005 at 0741 LT
Operator:
Registration:
C-GVCP
Flight Type:
Survivors:
No
Schedule:
Nanaimo – Comox
MSN:
31-7652080
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft was on a scheduled cargo flight from Nanaimo, British Columbia, to the civilian terminal on the south side of the military airbase at Comox, British Columbia. The crew members established communication with the Comox tower when they were at about 2000 feet over Hornby Island, 12 nautical miles southeast of Comox, and requested a practice back course/localizer approach to Runway 30, circling for landing on Runway 18. The request was approved and the aircraft continued inbound. When the aircraft was about two miles from the threshold of Runway 30, the crew declared an emergency for an engine fire in the right engine. The tower alerted the airport response teams and requested standard data from the crew concerning the number of people and amount of fuel on board. Less than 30 seconds after the crew first reported the emergency, the aircraft was engulfed in flames. Shortly thereafter, at 0741 Pacific daylight time, the aircraft rolled inverted and struck the ground in a steep, nose-down, left-wing-low attitude. The aircraft broke apart and burned. Both crew members were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. At some point after 01 April 1999, a bad gasket (P/N LW-13388) was installed in the accident engine.
2. The requirement of Airworthiness Directive 2002-12-07 (to ensure that old converter plate gaskets were removed and replaced by new parts) was not carried out on the accident engine.
3. The improper oil filter converter plate gasket in the right engine compartment failed, allowing pressurized oil to spray into the engine compartment and ignite on contact with hot turbocharger and exhaust components.
4. The firewall fuel shut-off valve remained in the OPEN position, allowing pressurized fuel to be delivered to the engine-driven fuel pump by the aircraft’s boost pumps.
5. The initial oil-fed fire generated considerable heat, which melted the casing of the engine-driven fuel pump, allowing pressurized fuel to intensify the fire.
6. The flames breached the main fuel tank, inboard of the engine, causing the aircraft to become engulfed in flames.
Findings as to Risk:
1. Inappropriate converter plate gaskets, identified by part number LW-13388, are known to have remained in the aviation system after the date of the terminating action required by Airworthiness Directive (AD) 2002-12-07.
2. Compliance with the full requirements of AD 2002-12-07 is not always being accomplished with respect to vibro-peening and proper gluing procedures.
Final Report:

Crash of an Antonov AN-12B in Al Mukalla

Date & Time: Mar 31, 2005 at 1902 LT
Type of aircraft:
Registration:
UN-11007
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Al Mukalla – Sharjah
MSN:
9 3 465 09
YOM:
1969
Flight number:
BIS6311
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
35115
Aircraft flight cycles:
13125
Circumstances:
The four engine aircraft was completing a cargo flight from Al Mukalla to Sharjah with eight crew members on board and a load consisting of 7 tons of fish. During the takeoff roll on runway 06, at a speed of 225 km/h, the nose gear collapsed. The captain initiated an emergency braking procedure. To avoid a collision with the radio-technical equipment car, he steered the aircraft to the left. After it veered off runway, the aircraft rolled for about 400 metres and came to rest in a sandy area about 30 metres to the left of the extended centerline. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
For unknown reasons, the flight engineer retracted the landing gear prematurely during the takeoff procedure without any instruction from the captain. Actions of flight engineer in violation of technology of standard operating procedures, by fixing of landing gear switch to 'retract position' after that to "neutral" without report to the Captain leaded to rise and development of occurrence.

Crash of a PZL-Mielec AN-28 in Kampene: 3 killed

Date & Time: Mar 30, 2005
Type of aircraft:
Registration:
3C-ZZY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kampene – Goma
MSN:
1AJ005-23
YOM:
1989
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Shortly after takeoff from Kampene Airport, while in initial climb, one of the engines failed. The aircraft lost height and crashed. Both pilots and one passenger were killed while the second passenger was seriously injured.
Probable cause:
Engine failure for unknown reasons. It was reported that the aircraft was parked somewhere in DRC for almost 2 years without flying. The aircraft was sent to fetch some cargo from Kampene without having undergone the required maintenance.

Crash of a Cessna 208B Caravan in Fazenda Vera Paz

Date & Time: Mar 29, 2005 at 0724 LT
Type of aircraft:
Operator:
Registration:
PT-MPA
Flight Type:
Survivors:
Yes
Schedule:
Itaituba – Fazenda Vera Paz
MSN:
208B-0627
YOM:
1997
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15000
Captain / Total hours on type:
4200.00
Circumstances:
The single engine airplane departed Itaituba-Mundico Coelho Airport on a cargo flight to Fazenda Vera Paz, a private airstrip located 360 km southwest from Itaituba Airport, carrying one pilot and a load of foods. After touchdown on runway 32, the pilot lost control of the aircraft that veered off runway to the left and came to rest in a drainage ditch, bursting into flames. The pilot escaped uninjured while the aircraft was destroyed by fire.
Probable cause:
Loss of control on landing for unknown reasons. It was not possible to determine whether the heavy rainfall that occurred in the region effectively contributed to the loss of control of the aircraft on the ground. In addition to the narrowing of the runway, the position of the drainage ditch became an obstacle, which prevented the aircraft from decelerating safely, culminating in the collision of the front landing gear against it and the impact of the propeller on the ground.
Final Report:

Crash of an Ilyushin II-76TD off Mwanza: 8 killed

Date & Time: Mar 23, 2005 at 2305 LT
Type of aircraft:
Operator:
Registration:
ER-IBR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mwanza – Khartoum – Benghazi – Osijek
MSN:
0043 4546 23
YOM:
1984
Flight number:
RIN982
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
11609
Captain / Total hours on type:
8939.00
Copilot / Total flying hours:
4769
Aircraft flight hours:
2615
Aircraft flight cycles:
1548
Circumstances:
On 23 March 2005 at 0533 hours an Ilyushin IL-76 cargo jet with the Republic of Moldova registration letters ER-IBR landed at Mwanza on a flight from Benghazi, Libya. It was carrying a crew of 8 including 2 ground engineers. All the 8 crew members were later involved in the accident. While at Mwanza, some 50,000 kg of fish was uplifted. At 1930 hours the commander filed a flight plan for Khartoum. The endurance was 0450 hours. The cargo manifest showed that ER-IBR was operating Air Trans Inc. Flight RIN 982 from Mwanza to Osijek, Croatia, with refueling stops at Khartoum and Benghazi. At 2000 hours the aircraft was given information relevant for take off as well as the departure clearance. ER-IBR subsequently advised that he was starting the take-off roll. This was the last communication received from the aircraft. The aircraft was observed to execute a normal take-off roll from runway 30. This runway ends 120m short of Lake Victoria. After observing that the aircraft was airborne, the controller who was handling the flight reported that he turned to complete the flight progress strip. Having done so, he lost visual contact with the aircraft that was supposed to be in a climb profile over the lake. Efforts to raise the aircraft on the radio failed. In about two minutes from the time that the aircraft was airborne, he saw a fire tender speeding along runway 30. It was then that he realized that the flight may have crashed. The Mwanza Airport Rescue and Fire Fighting Services were not equipped for operations in the lake. They were therefore unable to reach the aircraft, which was more than 1 km away from the shore. It was the fishermen at the lake shore near Mwanza airport who saw the aircraft going down in the lake. They proceeded to the crash site in fishing boats and brought back some documents (flight manuals and wiring diagrams) which they found floating near the wreckage.
Probable cause:
The accident was caused by aircraft colliding with the water surface shortly after take off. While the aircraft had gathered sufficient energy to sustain climb, the crew failed to monitor altitude and react correctly in the short time that the aircraft was airborne. This resulted in the aircraft going into descent till it reached an altitude where recovery was not possible. The possibility of crew fatigue as a contributory factor in this accident cannot be ruled out.
Final Report:

Crash of a Boeing 707-3K1C off Entebbe

Date & Time: Mar 19, 2005 at 1053 LT
Type of aircraft:
Registration:
9G-IRL
Flight Type:
Survivors:
Yes
Schedule:
Addis Ababa - Entebbe - Lomé
MSN:
20805
YOM:
1974
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a cargo flight from Addis Ababa to Lomé, Togo, with an intermediate stop in Entebbe, Uganda, carrying five crew members and a load of 32,8 tons of various goods (T-shirts) on behalf of Ethiopian Airlines. On approach to runway 17 in a 8 km visibility, the captain decided to initiate a go-around procedure. Few minutes later, while on a second attempt to land on runway 35, the crew encountered local patches of fog when, on short final, the aircraft crashed in Lake Victoria. The tail was found about 200 metres offshore while the cockpit was found near the shore. All five occupants were injured.
Probable cause:
The crew continued the approach below MDA until the aircraft impacted water and crashed. The crew failed to follow the published procedures and to initiate a second go-around procedure.

Crash of an Antonov AN-24B in Impfondo

Date & Time: Mar 4, 2005
Type of aircraft:
Operator:
Registration:
EY-46399
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Impfondo – Brazzaville
MSN:
0 73 063 03
YOM:
1970
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll, at Vr speed, the pilot-in-command pulled on the control column but the aircraft failed to respond. The captain rejected takeoff but the aircraft was unable to stop within the remaining distance. It overran an came to rest, bursting into flames. All five occupants escaped uninjured while the aircraft was totally destroyed by fire.

Crash of a Hawker-Siddeley HS.780 Andover CC.2 in Old Fangak

Date & Time: Feb 15, 2005
Operator:
Registration:
9XR-AB
Flight Type:
Survivors:
Yes
Schedule:
Lokichogio - Old Fangak
MSN:
1564
YOM:
1965
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was damaged beyond repair following a landing accident. There were no casualties among the crew and the aircraft was damaged beyond repair. The accident occurred somewhere in February, exact date unknown.