Crash of a Beechcraft C-45H Expeditor in Kodiak: 1 killed

Date & Time: Jun 14, 2004 at 1137 LT
Type of aircraft:
Operator:
Registration:
N401CK
Flight Type:
Survivors:
No
Schedule:
Anchorage – Kodiak
MSN:
AF-60
YOM:
1952
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
18600
Circumstances:
The solo airline transport pilot departed on a commercial cargo flight in a twin-engine, turboprop airplane. As the flight approached the destination airport, visibility decreased below the 2 mile minimum required for the initiation of the approach. The pilot entered a holding pattern, and waited for the weather to improve. After holding for about 45 minutes, the ceiling and visibility had improved, and the flight was cleared for the ILS 25 instrument approach. After the pilot's initial contact with ATCT personnel, no further radio communications were received. When the flight did not reach the destination airport, it was reported overdue. A search in the area of an ELT signal located the accident airplane on a hilly, tree-covered island. A witness located to the north of the airport reported seeing a twin-engine turboprop airplane flying very low over the water, headed in an easterly direction, away from the airport. The witness added that the weather at the time consisted of very low clouds, fog, and rain, with zero-zero visibility. A local resident also stated that the weather conditions were often much lower over the water adjacent to the approach end of the airport than at the airport itself. The missed approach procedure for the ILS 25 approach is a climbing left turn to the south. About one minute after the accident, a special weather observation was reporting, in part: Wind, 060 degrees (true) at 11 knots; visibility, 2 statute miles in light rain and mist; clouds and sky condition, 500 feet broken, 900 feet broken, 1,500 feet overcast; temperature, 46 degrees F; dew point, 44 degrees F. According to FAA records, the company was not authorized to conduct single pilot IFR operations in the accident airplane, and that the accident pilot was the operator's chief pilot. Toxicology tests revealed cocaethylene and chlorpheniramine in the pilot's blood and urine.
Probable cause:
The pilot's failure to follow proper IFR procedures by not adhering to the published missed approach procedures, which resulted in an in-flight collision with tree-covered terrain. Factors contributing to the accident were a low ceiling, fog, rain, and the insufficient operating standards of company management by allowing unauthorized single pilot instrument flight operations. Additional factors were the pilot's impairment from cocaine, alcohol, and over the counter cold medication, and the FAA's inadequate medical certification of the pilot and follow-up of his known substance abuse problems.
Final Report:

Crash of an Antonov AN-26B in Geneina

Date & Time: Jun 7, 2004
Type of aircraft:
Operator:
Registration:
ST-ARO
Flight Type:
Survivors:
Yes
Schedule:
Khartoum – Al Fashir – Geneina
MSN:
102 05
YOM:
1980
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing, the aircraft was unable to stop within the remaining distance. It overran, crossed an unpaved road and some ditches before coming to rest 250 meters further. All 16 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Following a wrong approach configuration, the crew landed too far down the runway, reducing the landing distance available.

Crash of an Antonov AN-32 in Kigali

Date & Time: Jun 1, 2004 at 0700 LT
Type of aircraft:
Operator:
Registration:
9XR-SN
Flight Type:
Survivors:
Yes
Schedule:
Beni – Goma
MSN:
21 05
YOM:
1989
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a cargo flight from Beni to Goma with 8 Congolese passengers and 4 Russians crew members on board. After takeoff from Beni, the captain reported technical problem with the left main gear but continued towards Goma. While descending to Goma Airport, he decided to divert to Kigali International Airport to make an emergency landing because of the gear problems. Upon landing, the aircraft bounced then veered off runway and came to rest. All 12 occupants were seriously injured and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 3 killed

Date & Time: May 25, 2004 at 1356 LT
Operator:
Registration:
9N-AFD
Flight Type:
Survivors:
No
Site:
Schedule:
Kathmandu - Lukla
MSN:
651
YOM:
1979
Flight number:
YET117
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
While descending to Lukla Airport from the south following a cargo flight from Kathmandu, the crew encountered poor visibility due to clouds when, at an altitude of 11,600 feet, the aircraft struck the slope of a mountain located near the Lamjura Pass, in the Solukhumbu district. The wreckage was found west of the airport and all three crew members were killed.
Probable cause:
Controlled flight into terrain. The following factors were identified:
- Hazardous behaviour and attitudes of the captain such as overconfidence,
- The crew failed to comply with the approach routes, following a direct track,
- The crew failed to follow SOP's,
- The operator's policy for flying in adverse weather were incomplete and not up to date,
- Lack of communication by the operator,
- The operator was unable to perform internal investigations and execute corrective actions when required.

Crash of a Let L-410UVP-E3 near Mwingi: 2 killed

Date & Time: May 23, 2004 at 0730 LT
Type of aircraft:
Operator:
Registration:
5Y-VVD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nairobi - Mogadishu
MSN:
87 20 09
YOM:
1987
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Nairobi-Wilson Airport on a cargo flight to Mogadishu, carrying two pilots and a load of 1,500 kilos of khat. About an hour into the flight, while in cruising altitude, the aircraft collided with a second Let L-410UVP also operated by Bluebird Aviation and registered 5Y-VVA. While the crew of 5Y-VVA was able to complete an emergency landing and the aircraft suffered small damages, 5Y-VVD entered an uncontrolled descent and crashed 30 km south of Mwingi, killing both pilots.

Crash of an Ilyushin II-76TD in Ürümqi: 7 killed

Date & Time: May 18, 2004 at 1050 LT
Type of aircraft:
Registration:
4K-AZ27
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Taiyuan – Ürümqi – Baku – Riga
MSN:
00534 60827
YOM:
1985
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
The aircraft was completing a cargo flight from Taiyuan to Riga with intermediate stops in Ürümqi and Baku, carrying seven crew members and a load of clothes. Two minutes after takeoff, while climbing, the aircraft stalled and crashed near a farm located 10 km from the airport. The aircraft was partially destroyed by impact forces and a post crash fire and all seven occupants were killed. Weather conditions were good at the time of the accident with a wind from 170 at 36 km/h.

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

Date & Time: May 14, 2004 at 0724 LT
Type of aircraft:
Operator:
Registration:
N755AF
Flight Type:
Survivors:
No
Site:
Schedule:
Philadelphia - Baltimore
MSN:
755
YOM:
1980
Flight number:
EPS101
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
6800
Aircraft flight hours:
6951
Circumstances:
The pilot was finishing his third round-trip, Part 135 cargo flight. The first round trip began the previous evening, about 2150, and the approach back to the origination airport resulted in a landing on runway 15R at 2305. The second approach back to the origination airport resulted in a landing on runway 28 at 0230. Prior to the third approach back to the airport, the pilot was cleared for, and acknowledged a visual approach to runway 33R twice, at 0720, and at 0721. However, instead of proceeding to the runway, the airplane flew north of it, on a westerly track consistent with a modified downwind to runway 15L. During the westerly track, the airplane descended to 700 feet. Just prior to an abeam position for runway 15L, the airplane made a "sharp" left turn back toward the southeast, and descended into the ground. Witnesses reported the airplane's movements as "swaying motions as if it were going to bank left, then right, and back left again," and "the nose...pointing up more than anything...but doing a corkscrew motion." Other witnesses reported the "wings straight up and down," and "wings vertical." Tower controllers also noted the airplane to be "low and tight," and "in an unusually nose high attitude close to the ground. It then "banked left and appeared to stall and then crashed." A post-flight examination of the wreckage revealed no evidence of mechanical malfunction. The pilot, who reported 6,800 hours of flight time, had also flown multiple round trips the previous two evenings. He had checked into a hotel at 0745, the morning prior to the accident flight, checked out at 1956, the same day, and reported for work about 1 hour before the first flight began.
Probable cause:
The pilot's failure to maintain airspeed during a sharp turn, which resulted in an inadvertent stall and subsequent impact with terrain. Factors included the pilot's failure to fly to the intended point of landing, and his abrupt course reversal back towards it.
Final Report:

Crash of an Antonov AN-12BP near Tatal: 7 killed

Date & Time: May 11, 2004 at 1018 LT
Type of aircraft:
Operator:
Registration:
ST-SIG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Juba - El Obeid
MSN:
14 001 01
YOM:
1961
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
7
Aircraft flight hours:
16609
Aircraft flight cycles:
7753
Circumstances:
En route from Juba to El Obeid, while cruising at an altitude of 24,000 feet, all four engines flamed out. The crew feathered the propeller, reduced his altitude and attempted an emergency landing when the aircraft struck the ground and crashed against trees. One occupant was seriously injured while six others were killed. Few hours later, the only survivor died from his injuries. It was reported that the aircraft was performing several round trips between Juba and El Obeid since May 9, each time with 9018 kgs of fuel uplifted in El Obeid while the average fuel consumption for a round trip was 10000 kgs. The crew was composed of an Armenian captain and ground engineer, a Sudanese first officer, a Sudanese navigator, a Sudanese radio operator, an Iraqi navigator and an Iraqi flight engineer.
Probable cause:
The following findings were identified:
- Fuel starvation due to Company fuel planning policy,
- The exhaustion of the Captain as he was handling all flights during the three days preceding the accident flight in addition to the weather on day of accident,
- Some of the crew members had limited experience on the type and three of them even did not fly on AN-12 for a long time which might aggravate the situation before the crash,
- The Sudanese navigator license was expired since July 2001,
- The Iraqi crew members did not have any valid licenses and their experience on the An-12 dated back from 1994,
- The aircraft's Certificate of Release to Service and Certificate of Maintenance Review both expired on April 30, 2004.

Ground explosion of a Douglas C-54B-1-DC Skymaster in Ganes Creek

Date & Time: May 7, 2004 at 2130 LT
Type of aircraft:
Operator:
Registration:
N44911
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Ganes Creek – Fairbanks
MSN:
10461
YOM:
1945
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11250
Captain / Total hours on type:
5630.00
Copilot / Total flying hours:
7465
Copilot / Total hours on type:
1560
Aircraft flight hours:
29667
Circumstances:
The crew of the 4 engine airplane started its engines for a positioning flight from a remote mining airstrip. Following the startup of the engines, an explosion occurred in the left wing area aft of the number 1 engine firewall and number 1 auxiliary fuel tank. The airplane was parked next to the mine's fuel storage tank, and the pilot added power on the remaining engines to move away from the storage tank. Within seconds of beginning to move, the number 1 engine fell off the burning wing, followed by separation and aft folding of the outboard end of the left wing. The outboard end of the wing, however, was still attached via control cables. The pilot taxied the airplane about 200 feet, dragging the partially burning left wing segment to a pond of water and shut down the remaining engines. The crew evacuated with no injuries. Water was applied to the airplane until the fire was extinguished, about 3 1/2 hours later. NTSB and FAA personnel did not travel to the scene, and the airplane was not recovered from the mining strip. The airplane's left wing powerplant and fuel system consists of the number 1 and 2 engines. Each engine is separated from the wing by a firewall. Within the wing, from outboard to inboard, the fuel tank system consists of the number 1 fuel tank, the left wing auxiliary fuel tank, and the number 2 fuel tank. Each wet-wing type fuel tank contains a submerged electrical boost pump, sump drain valves and fuel quantity transmitters. The fuel system has selector valves, crossfeed valves, and shut-off valves for each tank. An FAA inspector examined portions of the airplane that the operator supplied. The inspector examined a portion of the upper wing surface that had been blown away from the airplane during the initial explosion. He noted that the inside of the upper wing surface, normally positioned over the auxiliary tank, was not charred or sooted. A separated portion of the lower wing surface, near the auxiliary boost pump, was sooted and charred. The aft side of the number 1 engine firewall was not charred. A portion of the number 1 engine nacelle was oily, but not sooted or charred. The operator located the auxiliary in-tank boost pump and sent it to the FAA. The boost pump impeller, encased in a small wire cage, was not melted and could be turned by hand. The body of the pump was sooted but not thermally damaged. Its wire connectors and one fuel line were melted. A smaller line, what appeared to be a return line, was not melted.
Probable cause:
A fuel tank explosion in the left wing auxiliary fuel tank, and subsequent fuel fire that occurred during engine start for an undetermined reason.
Final Report:

Crash of a Douglas DC-10-30F in Bogotá

Date & Time: Apr 28, 2004 at 0356 LT
Type of aircraft:
Operator:
Registration:
N189AX
Flight Type:
Survivors:
Yes
Schedule:
Miami – Bogotá
MSN:
48277
YOM:
1981
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
77864
Aircraft flight cycles:
12224
Circumstances:
Following an uneventful cargo flight from Miami-Intl Airport on behalf of Lineas Aéreas Suramericanas, the crew started a night approach to Bogotá-El Dorado Airport. On final, the aircraft was unstable and too low when the GPWS alarm sounded five times. The captain increased engine power and elected to gain height, causing the aircraft to continue over the glide. At an excessive speed of 180 knots, the aircraft landed 1,500 feet past the runway 13L threshold (runway 13L is 3,800 metres long). After touchdown, the crew started the braking procedure but unable to stop within the remaining distance, the aircraft overran. It lost its undercarriage, collided with the ILS equipment, lost both engines n°1 and 3 and eventually came to rest few hundred metres further in a grassy area. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Departure from runway 13 left the El Dorado airport as a result of a landing with a speed of 180 knots and 1500 feet from the threshold, during which the spoilers were not used and in which there was hydroplaning by the main landing gear making the braking action less than expected. The decision of the crew to continue the approach despite the fact that this was not stabilized in accordance with the criteria described in the manual of operations of the airline. The omission of points in the checklist and call out from the crew that resulted in a lower alert situation facing the parameters of the approach and monitoring the operation of key systems such as the extension of spoilers after the landing. The non-response to the ground proximity warning system that is sounded for at least five times during the final approach in two different modes.