Crash of a Beechcraft 200 Super King Air in Perth

Date & Time: Apr 9, 2007 at 1703 LT
Operator:
Registration:
VH-SGT
Survivors:
Yes
Schedule:
Perth - Mount Hale
MSN:
BB-73
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 9 April 2007, at 1703 Western Standard Time (WST), the main landing gear from a Beech Super King Air 200 aircraft, registered VH-SGT, collapsed on landing at Perth airport. Approximately two hours earlier, the aircraft was chartered to fly from Perth to Mount Hale, WA when shortly after takeoff from Perth the aircraft experienced a malfunction of the landing gear system. The main wheels and nose gear had become jammed and were unable to fully retract when selected up by the pilot. The pilot completed the emergency checklist actions contained in the Aircraft Flight Manual, but was unable to retract or extend the gear using either the automated control or the manual emergency system. The pilot then requested assistance from a passenger to operate the manual emergency extension system. The landing gear remained jammed despite the additional force applied to the lever from the passenger. The pilot contacted air traffic services and requested further assistance from company engineering personnel to visually assess the extension state of the landing gear. Two aerodrome passes were completed throughout the troubleshooting exercise and the pilot remained in radio contact with both groups during this phase. Following the flyovers and after holding over Rottnest Island at 5,000 ft for a period of approximately two hours, the pilot flew the King Air back to Perth airport. With the gear still jammed in the partially retracted position, both the left and right main landing gear assemblies collapsed after the aircraft touched down on Runway 24. The aircraft was substantially damaged as a result of the collapse (Figure 1). The airport Rescue and Fire Fighting (RFF) services and other relevant agencies had been alerted and were waiting in response when the King Air landed. No injuries were sustained by the pilot or any of the nine passengers on board.
Probable cause:
From the evidence available, the investigation revealed that two major system components had failed which could have prevented the Beechcraft Super King Air 200 landing gear from properly retracting after takeoff. The following findings with respect to those failed landing gear system components should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The left torque tube support bearing had not been lubricated and had seized due to the accumulation of dirt and grit contaminants that had migrated from the external service environment and into the bearing.
• The geared components within the right main landing gear actuator prematurely failed.
Other safety factors:
• The aircraft manufacturer’s maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.
Other key findings:
• Both component assemblies were integral to the function and normal operation of the Super King Air 200 mechanical landing gear system. A break down of either component assembly would have prevented any attempt by the pilot to retract or extend the aircraft’s main landing gear. However, while either failure could have produced the landing gear difficulties sustained, the investigation was not able to determine which mechanism was the principal contributor to the event.
• The investigation was unable to conclusively establish why the geared components within the right main landing gear actuator had prematurely failed.
• The lower thrust bearing within the right main landing gear actuator had been correctly installed.
Final Report:

Crash of a Rockwell Shrike Commander 500S in São Sebastião do Passé: 4 killed

Date & Time: Mar 14, 2007 at 1355 LT
Operator:
Registration:
PP-SEC
Flight Phase:
Survivors:
No
Schedule:
Petrolina – Salvador
MSN:
500-3094
YOM:
1971
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
6858
Captain / Total hours on type:
2368.00
Aircraft flight hours:
15843
Circumstances:
The twin engine aircraft departed Petrolina Airport at 1221LT on a flight to Salvador, carrying 2 passengers, 2 pilots and a load of bags containing bank documents. At 1332LT, while in cruising altitude, the crew contacted ATC and reported an engine failure. The captain elected to make an emergency landing and reduced his altitude when the aircraft entered a right turn and crashed in a field located in São Sebastião do Passé, about 50 km northwest of Salvador Airport. The aircraft was destroyed upon impact and all four occupants were killed.
Probable cause:
Engine failure in flight following a fuel exhaustion. It was determined that the crew failed to prepare the flight properly and did not calculate the fuel consumption correctly. Investigations determined that the crew calculated a fuel consumption of 100 liters per hour while the true consumption was 120 liters per hour. The following contributing factors were identified:
- Overconfidence on part of the crew,
- Poor organisational culture that affected flight safety,
- Poor flight planning,
- The crew failed to feather the propeller following the engine failure, causing drag and contributing to the loss of control at low height.
Final Report:

Crash of a Britten-Norman BN-2B-26 Islander in Ruhnu Island

Date & Time: Mar 3, 2007 at 1608 LT
Type of aircraft:
Operator:
Registration:
D-ILFB
Survivors:
Yes
Schedule:
Pärnu - Ruhnu Island
MSN:
2271
YOM:
1994
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16079
Aircraft flight hours:
2811
Aircraft flight cycles:
27857
Circumstances:
Luftverkehr Friesland Brunzema und Partner KG, registered in Germany and holding the Air Operator Certificate issued by the Federal Republic of Germany in 1983, has been operating scheduled flights between Pärnu (EEPU) and Ruhnu (EERU) since 2006. The flight, initially planned for 26th February 2007, was postponed several times due to adverse meteorological conditions, causing problems with provision supply on the island. On Friday, 3rd March, pilot checked the weather at 13:00 and at 14:00. Based on the received information the pilot decided to depart for Ruhnu at 14:00. At 14:08, the aircraft took off from Pärnu airport to make a scheduled VFR flight to the island of Ruhnu. Flight was carried out in the uncontrolled airspace. Pilot, two passengers and 520 kg of cargo were on board the aircraft. According to the weather briefing received by the pilot via telephone from Kuressaare, at 14:00 the cloud height in Kuressaare (EEKE, 36 Nm northwest of Ruhnu) was 600 ft. and 180 m (approximately 540 ft.) in Ruhnu. During the uneventful flight on the altitude 1500 ft., the coast and the ice border were clearly visible. The aircraft stayed clear from the clouds and no signs of icing were noticed by persons on board. Approaching the island from the northeast it was intended by the pilot to use RWY 32 for landing. The pilot decided to fly low from east to west across the runway to check the windsock and runway condition. While approaching the island, the pilot descended at the rate of 150 ft/min with low power settings and flaps extended by 1 notch. During descent the horizontal and vertical visibility deteriorated and the flight was continued in IMC2 . The descent was continued in clouds; therefore the pilot had no visual contact with the ground and horizon. The aircraft broke off the clouds over the coast on a very low altitude (100-120 ft. by pilot’s statement). Trying to maintain safe altitude and speed pilot added power, at the same time stall warning signal activated and seconds later the lower part of aircraft’s fuselage touched the treetops and collided with the terrain at 14:36. The engines continued producing power until collision with trees which after those were set to the idle by pilot. The passengers and pilot escaped the aircraft without assistance and with no injuries. The accident site is situated 0.24 Nm northeast off the runway 32 threshold. Ground surface is uneven and forested with young pinewoods.
Probable cause:
The investigation established the following causes of the accident:
1. The pilot could not maintain safe flight altitude when approaching Ruhnu aerodrome.
2. The pilot continued the descent in spite of IMC.
Contributing factors to the accident:
The investigation established the following factors contributing to the accident:
1. High motivation to perform the flight.
2. Inadequate weather information from ground services of Ruhnu aerodrome.
3. Inadequate aeronautical oversight in the destination airport.
Final Report:

Crash of a De Havilland DHC-2 Beaver I near La Grande-4

Date & Time: Jan 21, 2007 at 1212 LT
Type of aircraft:
Operator:
Registration:
C-GUGQ
Flight Phase:
Survivors:
Yes
MSN:
400
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1200
Captain / Total hours on type:
400.00
Circumstances:
The ski-equipped aircraft took off around 1130 eastern standard time from Mirage Outfitter, located 60 miles east of La Grande-4 Airport, Quebec, with a pilot and four passengers on board, to locate caribou herds. About 40 minutes after departure, the engine stopped as a result of fuel starvation. The pilot was not able to regain power and made a forced landing on rugged ground. The aircraft was heavily damaged and two passengers were seriously injured. The pilot used a satellite telephone to request assistance. First-aid assistance arrived by helicopter about 1 hour 30 minutes after the occurrence. The aircraft fuel system had been modified after the installation of wings made by Advanced Wing Technologies Corporation.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The engine stopped as a result of fuel starvation; the amount of fuel in the wings was less than the amount estimated by the pilot, the fuel senders gave an incorrect reading, and the low fuel pressure warning light could illuminate randomly.
2. The engine stopped at low altitude, which reduced the time needed to complete the emergency procedure. The pilot was unable to glide to the lake and made a forced landing on an unsuitable terrain, causing significant damage to the aircraft and injuries to the occupants.
Findings as to Risk:
1. The wing tank selection system was subject to icing in cold weather, and the pilots adopted the practice to place the wing tank selector in the middle position, which is contrary to the aircraft flight manual supplement instructions and a placard posted on the instrument panel.
2. When the change to the type design was approved through issuance of the Supplementary Type Certificate (STC), Transport Canada did not notice the fact that the fuel senders and triple fuel level gauge did not meet airworthiness standards; Transport Canada issued an STC that contained several deficiencies. 3. Storage of the shoulder harnesses underneath the aircraft interior covering made them inaccessible; since the pilot and the front seat passenger did not wear their shoulder harness, their protection was reduced.
Final Report:

Crash of a Rockwell Grand Commander 690A in Valledupar: 4 killed

Date & Time: Jan 13, 2007 at 2122 LT
Operator:
Registration:
YV-246CP
Flight Phase:
Survivors:
No
Site:
Schedule:
Maracaibo – Panama City
MSN:
690-11278
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
18829
Captain / Total hours on type:
781.00
Aircraft flight hours:
8197
Circumstances:
The twin engine aircraft departed Maracaibo Airport on a charter flight to Panama City with three passengers and one pilot on board. While cruising over the Sierra de Perija between Venezuela and Colombia, the pilot informed ATC about technical problems. Shortly later, the aircraft entered an uncontrolled descent and crashed in a mountainous terrain near Valledupar, bursting into flames. All four occupants were killed.
Probable cause:
The exact cause of the loss of control could not be determined.
Final Report:

Crash of an Antonov AN-26B-100 in Balad: 34 killed

Date & Time: Jan 9, 2007 at 0702 LT
Type of aircraft:
Operator:
Registration:
ER-26068
Survivors:
Yes
Schedule:
Adana – Balad
MSN:
113 08
YOM:
1981
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
30
Pax fatalities:
Other fatalities:
Total fatalities:
34
Circumstances:
The aircraft was performing a charter flight from Adana, Turkey, to Balad AFB (located 70 km north of Baghdad), carrying 30 workers coming from Moldova, Russia, Turkey and Ukraine, on behalf of the Turkish Company Kulak specialized in reconstruction projects. The aircraft departed Adana Airport at 0600LT for a 90 minutes flight. On approach, the crew encountered poor visibility due to foggy conditions. Unable to locate the runway, the captain decided to initiate a go-around procedure. Few minutes later, while attempting a second approach, the aircraft descended too low and crashed 2,5 km short of runway, bursting into flames. A passenger was seriously injured while 34 other occupants were killed.
Probable cause:
The cause of the accident and the exact position of the aircraft during the last segment could not be determined with certainty as the FDR was not in the aircraft at the time of the accident.

Crash of a Piper PA-31-310 Navajo in Matambwe: 1 killed

Date & Time: Jan 5, 2007 at 0902 LT
Type of aircraft:
Registration:
5H-MUX
Survivors:
Yes
Schedule:
Dar es Salaam – Matambwe
MSN:
31-627
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1700
Circumstances:
The aircraft was carrying tourists, including the organizer of the trip to Matambwe. These passengers included five adults, a boy of sixteen, three girls of eleven, five and four years. There was also an infant of 11 months. This trip was arranged by a company called Tent with a View Safaris, which owns a camp at Matambwe in the Selous Game Reserve. According to the company, initially two aircraft were organized to transport the passengers to Matambwe. The booking was made through a telephone call to an operator called Wings of Zanzibar, who advised them to go to Terminal I of Julius Nyerere International Airport in Dar es Salaam. However, when the passengers arrived at the Wings of Zanzibar office at the airport, they found it closed. When Wings of Zanzibar was contacted on the telephone, a pilot employed by another company, DJB Ltd, was alerted to meet them. The pilot initially took them to the offices of DJB for payment. He also recommended that one aircraft would suffice for the trip. According to the pilot, he believed that the three children were small enough to sit on their parents’ laps. The passengers had little baggage. The aircraft, a Piper PA31-310 Navajo, took off from Dar es Salaam at 0825 hours and cruised at FL 65. The flight to Matambwe was uneventful and the aircraft was overhead the airstrip at 0902 hours. The pilot over flew the airstrip to alert the camp staff and check for wind and animals, a common procedure for landing in the Game Reserve airstrips. He also made another low run over the runway to ascertain its condition. Eye witnesses and passengers confirmed that the pilot made an overshoot, having flown very low attempting to land. The pilot was not sure of the runway condition because he had not flown into this airfield for a long time. In addition, before embarking on this trip, he had requested information on the runway condition from another pilot who had recently flown into the airstrip. He was told that the runway was usable. Finally, the pilot decided to land. He chose to land on runway 28 with full flaps. He touched down about two hundred and fifty meters beyond the beginning of the usable part of the runway and braked normally. After rolling for some time, he realized that the aircraft would not be able to stop before the end of the remaining length of the runway. With about another two hundred and fifty meters ahead, the pilot initiated a go round believing he had sufficient runway length remaining to gather enough speed for takeoff and climb out. He immediately increased power and initiated the go around. It is at this moment that the aircraft became airborne with no speed increase. The aircraft flew straight and level at full power without gaining height. It subsequently started chopping small tree tops for about two hundred meters beyond the end of the runway and then started to lose height. As it did so, the starboard wing collided with a large tree and the aircraft rotated through 180 degrees before coming to rest. The main wreckage settled below the impact tree and the passengers evacuated immediately. The wreckage caught fire immediately after the last passenger was evacuated. It burned completely, leaving only the tail fin and parts of the engine nacelle. When staff members from Tent with a View Camp located at Matambwe arrived, the aircraft was burning fiercely. They assisted in moving the occupants to a safer location, far from the burning wreckage and in administering first aid. The aircraft occupants were later treated at a local dispensary before being transported to a hospital in Dar es Salaam. One passenger died in the hospital four hours after the accident. Two passengers were treated for serious injuries. The injuries to the rest of the occupants were minor.
Probable cause:
The accident was caused by the aircraft colliding with trees just beyond the end of the runway. The failure to select the correct flap position for the take off, the lack of proficiency training, insufficient flight preparation and lack of real time information on the runway at Matambwe were contributory factors.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in Long Layu

Date & Time: Dec 30, 2006
Type of aircraft:
Operator:
Registration:
PK-VIN
Flight Phase:
Survivors:
Yes
MSN:
351
YOM:
1973
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While taking off from the grassy runway 01/19 which is 550 metres long, control was lost. The aircraft veered off runway and came to rest in a pond. There were no injuries but the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-6 Twin Otter 300 on Mt Puncak Jaya: 12 killed

Date & Time: Nov 17, 2006 at 0800 LT
Operator:
Registration:
PK-YPY
Flight Phase:
Survivors:
No
Site:
Schedule:
Mulia – Ilaga
MSN:
535
YOM:
1977
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
12
Circumstances:
The twin engine aircraft departed Mulia on a special flight to Ilaga, carrying a delegation of nine people flying to Ilaga to visit several districts of the Irian Jaya province on behalf of a talks between several administrations. While cruising at an altitude of 10,500 feet in marginal weather conditions, the aircraft struck Mt Puncak Jaya. The wreckage was found the following day. All 12 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a NAMC YS-11A-600 in Manila

Date & Time: Nov 16, 2006 at 1425 LT
Type of aircraft:
Operator:
Registration:
RP-C3590
Survivors:
Yes
Schedule:
Tacloban - Manila
MSN:
2106
YOM:
1969
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Tacloban on a charter flight to Manila, carrying five employees of the Philippines Central Bank and four crew members. Upon landing on runway 06, the aircraft veered off runway to the right, lost its right main gear and came to rest. All 9 occupants escaped uninjured while the aircraft was damaged beyond repair.