Crash of a Cessna 414 Chancellor in Linz

Date & Time: Feb 13, 2004 at 0615 LT
Type of aircraft:
Operator:
Registration:
OE-FRW
Flight Phase:
Survivors:
Yes
Schedule:
Linz - Stuttgart
MSN:
414-0825
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2527
Captain / Total hours on type:
830.00
Copilot / Total flying hours:
522
Copilot / Total hours on type:
250
Aircraft flight hours:
4463
Circumstances:
The twin engine aircraft departed Linz-Hörsching Airport on a taxi flight to Stuttgart with five passengers and two pilots on board. During the takeoff roll on runway 27, at a speed of 105 knots, the crew started the rotation. Immediately after liftoff, the aircraft adopted a high nose attitude with an excessive angle of attack. It rolled to the left, causing the left gear door and the left propeller to struck the runway surface, followed shortly later by the right propeller. After the speed dropped, the aircraft stalled and crash landed on the runway. It slid for few dozen metres and came to rest 2,752 metres past the runway threshold. All seven occupants were evacuated, one passenger suffered serious injuries. The aircraft was damaged beyond repair.
Probable cause:
The loss of control immediately after liftoff was the consequence of an aircraft contaminated with ice, resulting in an excessive weight, a loss of lift and a consequent stall. The following factors were identified:
- Poor flight preparation,
- The crew failed to follow the SOP procedures prior to takeoff,
- The aircraft has not been deiced prior to takeoff, increasing the total weight of the aircraft by 231 kilos, 8% above the MTOW,
- This situation caused the CofG to be out of the permissible limits,
- Poor judgment on part of the crew when the undercarriage were lowered.

Crash of a Beechcraft 1900D in Ghardaïa: 1 killed

Date & Time: Jan 28, 2004 at 2101 LT
Type of aircraft:
Operator:
Registration:
7T-VIN
Survivors:
Yes
Schedule:
Hassi R’Mel – Ghardaïa
MSN:
UE-365
YOM:
1999
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
1742
Circumstances:
The aircraft departed Hassi R'Mel-Tilrhempt Airport at 2030LT on a 15-minutes charter flight to Ghardaïa, carrying three crew members and two employees of the Sonatrach (Société Nationale pour le Transport et la Commercialisation d’Hydrocarbures). At 2044LT, the crew was cleared for a right hand circuit in preparation for an approach to runway 30. At that moment a Boeing 727 inbound from Djanet was on long finals. The copilot stated that he intended to carry out an NDB/ILS approach to runway 30. The captain however preferred a visual approach. The copilot carried out the captain's course and descent instructions with hesitation. At 2057LT, the EGPWS alarm sounded. Power was added and a climb was initiated from a lowest altitude of 240 feet above ground level. The captain then took over control and assumed the role of Pilot Flying. The airplane manoeuvred south of the airport until 2101LT when the copilot saw the runway. The captain rolled left to -57° and pitched down to -18.9° in order to steer the airplane towards the runway. Again the EGPWS sounded but the descent continued until the airplane impacted the ground and broke up. All five occupants were injured and the aircraft was destroyed. A day later, the copilot died from his injuries.
Probable cause:
The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

Crash of an Ilyushin II-18D in Luena

Date & Time: Jan 27, 2004 at 1440 LT
Type of aircraft:
Operator:
Registration:
ER-ICJ
Flight Phase:
Survivors:
Yes
Schedule:
Luena – Luanda
MSN:
186 0091 02
YOM:
1966
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll on runway 29, the aircraft did not accelerate as expected. The captain decided to abort the takeoff procedure but the aircraft could not be stopped within the remaining distance. It overran and collided with trees located 100 meters further. A crew member was injured and the aircraft was damaged beyond repair.

Crash of a Boeing 737-3Q8 off Sharm el-Sheikh: 148 killed

Date & Time: Jan 3, 2004 at 0445 LT
Type of aircraft:
Operator:
Registration:
SU-ZCF
Flight Phase:
Survivors:
No
Schedule:
Sharm el-Sheikh - Cairo - Paris
MSN:
26283
YOM:
1992
Flight number:
FSH604
Country:
Region:
Crew on board:
13
Crew fatalities:
Pax on board:
135
Pax fatalities:
Other fatalities:
Total fatalities:
148
Captain / Total flying hours:
7443
Captain / Total hours on type:
474.00
Copilot / Total flying hours:
788
Copilot / Total hours on type:
242
Aircraft flight hours:
25603
Aircraft flight cycles:
17976
Circumstances:
Following a night takeoff from runway 22R at Sharm el Sheikh-Ophira Airport, the plane climbed and maneuvered for a procedural left turn to intercept the 306 radial from the Sharm el Sheikh VOR station. When the autopilot was engaged the captain made an exclamation and the autopilot was immediately switched off again. The captain then requested Heading Select to be engaged. The plane then began to bank to the right. The copilot then warned the captain a few times about the fact that the bank angle was increasing. At a bank angle of 40° to the right the captain stated "OK come out". The ailerons returned briefly to neutral before additional aileron movements commanded an increase in the right bank. The aircraft had reached a maximum altitude of 5,460 feet with a 50° bank when the copilot stated 'overbank'. Repeating himself as the bank angle kept increasing. The maximum bank angle recorded was 111° right. Pitch attitude at that time was 43° nose down and altitude was 3,470 feet. The observer on the flight deck, a trainee copilot, called 'retard power, retard power, retard power'. Both throttles were moved to idle and the airplane gently seemed to recover from the nose-down, right bank attitude. Speed however increased, causing an overspeed warning. At 04:45 the airplane struck the surface of the water in a 24° right bank, 24° nose-down, at a speed of 416 kts and with a 3,9 G load. The aircraft disintegrated on impact and debris sank by a depth of 900 metres. All 148 occupants were killed, among them 133 French citizens, one Moroccan, one Japanese and 13 Egyptian (all crew members, among them six who should disembark at Cairo). Weather at the time of accident was good with excellent visibility, outside temperature of 17° C and light wind. On January 17, the FDR was found at a depth of 1,020 metres and the CVR was found a day later at a depth of 1,050 metres.
Probable cause:
No conclusive evidence could be found from the findings gathered through this investigation to determine the probable cause. However, based on the work done, it could be concluded that any combination of these findings could have caused or contributed to the accident. Although the crew at the last stage of this accident attempted to correctly recover, the gravity upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Possible causes:
- Trim/Feel Unit Fault (Aileron Trim Runaway),
- Temporarily, Spoiler wing cable jam (Spoiler offset of the neutral position),
- Temporarily, F/O wheel jam (Spoilers offset of the neutral position),
- Autopilot Actuator Hardover Fault.
Possible contributing factors:
- A distraction developing to Spatial Disorientation (SD) until the time the F/O announced 'A/C turning right' with acknowledgment of the captain,
- Technical log copies were kept on board with no copy left at departure station,
- Operator write up of defects was not accurately performed and resulting in unclear knowledge of actual technical status,
- There are conflicting signals which make unclear whether the captain remained in SD or was the crew unable to perceive the cause that was creating an upset condition until the time when the F/O announced that there was no A/P in action,
- After the time then the F/O announced 'no A/P commander' the crew behavior suggests the recovery attempt was consistent with expected crew reaction, evidences show that the corrective action was initiated in full, however the gravity of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.
Additional findings:
- The ECAA authorization for RAM B737 simulator was issued at a date later than the date of training for the accident crew although the inspection and acceptance test were carried out at an earlier date.
- Several recorded FDR parameters were unreliable and could not be used for the investigation.
Final Report:

Crash of a De Havilland DHC-3 Otter in Jellicoe: 2 killed

Date & Time: Dec 16, 2003 at 1200 LT
Type of aircraft:
Operator:
Registration:
C-GOFF
Flight Phase:
Survivors:
Yes
MSN:
65
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5016
Captain / Total hours on type:
540.00
Circumstances:
At approximately 0900 eastern standard time (EST), the pilot arrived at the airstrip and prepared the ski-equipped de Havilland DHC–3 (Otter) aircraft (registration C–GOFF, serial number 65) for the morning flight. This Otter was equipped with a turbine engine. Two passengers, with enough supplies for an extended period of time, including a snowmobile and camping gear, were to be flown to a remote location. The pilot loaded the aircraft and waited for the weather to improve. At approximately 1200 EST, the pilot and passengers boarded the aircraft and took off in an easterly direction. The aircraft got airborne near the departure end of the airstrip, and, shortly after take-off, the right wing struck a number of small bushes and the top of a birch tree. The aircraft descended and struck the frozen lake surface, approximately 70 feet below the airfield elevation in a steep, nose-down, right-wing-low attitude. When it came to rest, the aircraft was inverted and partially submerged, with only the aft section of the fuselage remaining above the ice. All of the occupants were wearing lap belts. The pilot and front seat passenger received fatal injuries. The rear seat passenger survived the impact and evacuated the aircraft with some difficulty due to leg injuries. The following morning, about 22 hours after the accident, a local air operator searching for the missing aircraft located and rescued the surviving passenger.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot attempted to take off from an airstrip that was covered with approximately 18 inches of snow, and the aircraft did not accelerate to take-off speed because of the drag; the aircraft was forced into the air and was unable to climb out of ground effect and clear the obstacles.
2. The pilot did not abort the take-off when it became apparent that the aircraft was not accelerating normally and before the aircraft became airborne.
Findings as to Risk:
1. Unidirectional G switches, which are found on many types of ELTs, do not always activate the unit when impact forces are not aligned with the usual direction of flight.
Other Findings:
1. The validity of the aircraft’s certificate of airworthiness was affected while it flew more flights than allowed by the ferry permit issued by Transport Canada.
2. The rear passenger seat was found to be installed incorrectly, contrary to de Havilland Alert Service Bulletin A3/49, dated 19 July 1991.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Viekoda Bay

Date & Time: Nov 29, 2003 at 0935 LT
Type of aircraft:
Operator:
Registration:
N13VF
Survivors:
Yes
Site:
Schedule:
Kodiak – Viekoda Bay
MSN:
1613
YOM:
1965
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7103
Captain / Total hours on type:
3100.00
Aircraft flight hours:
14953
Circumstances:
During an on-demand air taxi flight, the airline transport certificated pilot was preparing to land an amphibious float-equipped airplane near a cabin that was located on the shore of a coastal bay. A 10 to 15 knot wind was blowing from the bay toward the land, and the pilot decided to approach over land. As the airplane descended over a small creek bed, adjacent to a hill, the airplane encountered a downdraft, and descended rapidly. The left wing collided with alder trees which spun the airplane 180 degrees. The right wing and float assembly were torn off the airplane. The closest official weather observation station, located 30 miles away, was reporting calm wind.
Probable cause:
The pilot's inadequate evaluation of the weather conditions, and his failure to maintain adequate altitude/clearance, which resulted in a collision with terrain during the final landing approach. A factor contributing to the accident was the presence of a downdraft.
Final Report:

Crash of a Learjet 24D in Saint Louis

Date & Time: Nov 12, 2003 at 0645 LT
Type of aircraft:
Operator:
Registration:
N77JL
Flight Phase:
Survivors:
Yes
Schedule:
Saint Louis – North Platte
MSN:
24-286
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9054
Captain / Total hours on type:
760.00
Copilot / Total flying hours:
3400
Copilot / Total hours on type:
150
Aircraft flight hours:
6653
Aircraft flight cycles:
6504
Circumstances:
The turbojet airplane was destroyed during a forced landing and post accident fire after a loss of power in both engines during takeoff climb. The pilot reported that both engines operated
normally during taxi and pre-takeoff checks. He reported that, "We rotated positive rate gear up, V2 plus 30 flaps up, and at that point we struck birds taking No. 2 engine out. Upon losing No. 2 engine I advanced thrust levers forward and realized that the No. 1 engine was only producing approximately 70% RPM with EGT over read line." He executed a forced landing to a field and the crew and passengers evacuated the burning airplane. The copilot reported, "At approximately 500 to 1,000 ft. above ground level, I observed a large flock of birds straight ahead of us, and then passing just off our nose to the left side. I immediately heard an engine flameout. As I started to go to the checklist for single engine operations, I quickly realized that we were loosing airspeed and unable to maintain altitude. The PIC said we were going down and heading for the best emergency-landing stop." The Cockpit Voice Recorder (CVR) recorded the pilot stating, "We hit a bird," and the copilot stating, "Yep," immediately following the CVR recording a "sound similar to decrease in engine RPM." The inspection of the airplane's fuel system, pneumatic system, engines, fuel controls and fuel pumps revealed no pre-impact anomaly. No physical evidence of bird ingestion was found in either engine. A CVR sound spectrum plot and a flight profile analysis revealed that one engine flamed out almost immediately after the sound of a "thump" on the CVR. The other engine's speed decreased and experienced stalls until the engine speed was reduced to flight idle. The original engine certification tests indicated that compressor stalls occurred when a 2-4 ounce starling was shot ingested into the engine, but physical damage from bird ingestion was very slight due to the all steel construction and geometry of the engine. Engine flameouts, however, were not recorded during the certification tests. A wildlife specialist conducted a bird count at the accident airport two days after the accident occurred, and he reported counting a flock of about 800 European Starlings.
Probable cause:
The total loss of power to the right engine and the partial loss of power to the left engine after the airplane encountered a flock of birds during initial climb out, resulting in impeded ram induction airflow.
Final Report:

Crash of a Short SC.7 Skyvan 3M Variant 100 in Georgetown: 2 killed

Date & Time: Nov 8, 2003 at 1100 LT
Type of aircraft:
Operator:
Registration:
8R-GMC
Flight Phase:
Survivors:
Yes
Schedule:
Georgetown – Ekereku
MSN:
1959
YOM:
1978
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
One minute after takeoff from Georgetown-Ogle Airport runway 24, the pilot declared an emergency after an engine failed. He elected to return for an emergency landing but eventually attempted to land in a sugarcane field when the aircraft crashed near the airport. Five people were seriously injured while two others were killed.
Probable cause:
Failure of the right engine during initial climb for unknown reasons.

Crash of an Antonov AN-2 in Tambovka

Date & Time: Nov 5, 2003
Type of aircraft:
Registration:
FLARF-00887
Flight Phase:
Survivors:
Yes
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following technical problems, the crew was forced to attempt an emergency landing. The aircraft crash landed and came to rest, bursting into flames. There were no casualties.

Crash of a Piper PA-31-310 Navajo in Gaspé: 3 killed

Date & Time: Sep 27, 2003 at 1857 LT
Type of aircraft:
Registration:
C-FARL
Survivors:
No
Schedule:
Le Havre-aux-Maisons - Gaspé
MSN:
31-306
YOM:
1968
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5262
Captain / Total hours on type:
3000.00
Circumstances:
The PA-31-310, registration C-FARL, serial number 31306, operated by Les Ailes de Gaspé Inc., with one pilot and two passengers on board, was on a visual flight rules flight from Îles-de-la-Madeleine, Quebec to Gaspé, Quebec. While en route to Gaspé, the pilot was informed about weather conditions at his destination, which were a ceiling at 500 feet and visibility of ¾ mile in fog. The pilot requested clearance for an instrument approach, which he received at approximately 1857 eastern daylight time. A few seconds later the pilot switched on the aerodrome lights with his microphone button. That was the last radio transmission received from the aircraft. When the aircraft did not arrive at its destination, emergency procedures were initiated to find it. The wreckage was found the next day at 1028 eastern daylight time on a hilltop 1.2 nautical miles (nm) north-east of the airport. The aircraft was destroyed, but did not catch fire. The three occupants were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot descended to the minimum descent altitude (MDA) without being established on the localizer track, thereby placing himself in a precarious situation with respect to the approach and to obstruction clearance.
2. On an instrument approach, the pilot continued his descent below the MDA without having the visual references required to continue the landing, and he was a victim of CFIT (controlled flight into terrain).
Findings as to Risk:
1. The aircraft was not, nor was it required to be, equipped with a ground proximity warning system (GPWS) or a radio altimeter, either of which would have allowed the pilot to realize how close the aircraft was to the ground.
2. The presence of a co-pilot would have allowed the pilots to share tasks, which undoubtedly would have facilitated identification of deviations from the approach profile.
3. The existing regulations do not provide adequate protection against the risk of ground impact when instrument approaches are conducted in reduced visibility conditions.
Other Findings:
1. The emergency locator transmitter (ELT) could not emit a distress signal because the battery disconnected on impact. Location of the aircraft was delayed until the day after the accident, which could have had serious consequences if there had been any survivors.
Final Report: