Crash of a Cessna 402B in Nassau

Date & Time: Apr 3, 2002 at 1210 LT
Type of aircraft:
Registration:
N768WC
Survivors:
Yes
Schedule:
Nassau - Bimini
MSN:
402B-1066
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On April 3, 2002, about 1210 eastern standard time, a Cessna 402B, N768WC, registered to and operated by Southstream Aviation, Inc., was ditched in Coral Harbor Lake, southwest of the Nassau International Airport, Nassau, Bahamas. Visual meteorological conditions prevailed at the time and a VFR flight plan was filed for the 14 CFR Part 91 personal flight to Bimini, Bahamas. The airplane was substantially damaged and the commercial-rated pilot and a passenger were not injured. The flight originated about 6 minutes earlier from the Nassau International Airport. According to the passenger who is a U.S. certificated pilot, the airplane was fueled before takeoff. He checked the fuel tanks for contaminants after fueling; none were found. The flight departed from runway 14, then when turning on course to Bimini, the left engine sputtered. The pilot reduced then increased power from the left engine which then quit. He noted at that time the manifold and fuel pressure indications were decreasing. The pilot then turned back towards the Nassau airport to return when the right engine quit. Unable to return to the airport, the pilot ditched the airplane in the lake; the airplane remained upright in the approximately 1-4 feet deep water. Both occupants exited the airplane unaided. The accident site was located approximately 2.6 nautical miles southwest of the Nassau International Airport.

Crash of a Mitsubishi MU-300 Diamond in Anderson

Date & Time: Mar 25, 2002 at 0901 LT
Type of aircraft:
Registration:
N617BG
Survivors:
Yes
Schedule:
Memphis – Anderson
MSN:
067
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10500
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
1575
Copilot / Total hours on type:
275
Aircraft flight hours:
4078
Circumstances:
The MU-300 on-demand passenger charter flight sustained substantial damage during a landing overrun on a snow/ice contaminated runway. The captain, who was also the company chief pilot and check airman, was the flying pilot, and the first officer was the non flying pilot. Instrument meteorological conditions prevailed at the time of the accident. Area weather reporting stations reported the presence of freezing rain and snow for a time period beginning several hours before the accident. The captain did not obtain the destination airport weather observation until the flight was approximately 30 nautical miles from the airport. The flight received radar vectors for a instrument landing system approach to runway 30 (5,401 feet by 100 feet, grooved asphalt). The company's training manual states the MU-300's intermediate and final approach speeds as 140 knots indicated airspeed (KIAS) and Vref, respectively. Vref was reported by the flight crew as 106 KIAS. During the approach, the tower controller (LC) gave the option for the flight to circle to land or continue straight in to runway 30. LC advised that the winds were from 050-070 degrees at 10 knots gusting to 20 knots, and runway braking action was reported as fair to poor by a snow plow. Radar data indicates that the airplane had a ground speed in excess of 200 knots between the final approach fix and runway threshold and a full-scale localizer deviation 5.5 nm from the localizer antenna. The company did not have stabilized approach criteria establishing when a missed approach or go-around is to be executed. The captain stated that he was unaware that there was 0.7 percent downslope on runway 30. The company provided a page from their airport directory which did not indicate a slope present for runway 30. The publisher of the airport directory provided a page valid at the time of the accident showing a 0.7 percent runway slope. Runway slope is used in the determination of runway performance for transport category aircraft such as the MU-300. The airplane operating manual states that MU-300 landing performance on ice or snow covered runways has not been determined. The airplane was equipped with a cockpit voice recorder with a remote cockpit erasure control. Readout of the cockpit voice recorder indicated a repetitive thumping noise consistent with manual erasure. No notices to airman pertaining to runway conditions were issued by the airport prior to the accident.
Probable cause:
Missed approach not executed and flight to a destination alternate not performed by the flight crew. The tail wind and snow/ice covered runway were contributing factors.
Final Report:

Crash of an Antonov AN-2 near Santa Clara: 17 killed

Date & Time: Mar 14, 2002 at 1623 LT
Type of aircraft:
Operator:
Registration:
CU-T1020
Flight Phase:
Survivors:
No
Schedule:
Cienfuegos - Caya Coco
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
17
Circumstances:
While cruising at an altitude of 3,000 feet on a charter flight from Cienfuegos to Cayo Coco, the single engine aircraft entered an uncontrolled descent and crashed in a prairie located near Santa Clara. The aircraft was totally destroyed and all 17 occupants were killed, among them 6 Canadians, five British, two German while all four crew members were Cuban. It was reported that the left upper wing detached while the aircraft was encountering strong winds.

Crash of a Beechcraft E90 King Air in Reno

Date & Time: Mar 13, 2002 at 1940 LT
Type of aircraft:
Operator:
Registration:
N948CC
Survivors:
Yes
Site:
Schedule:
Durango - Truckee
MSN:
LW-236
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1610
Captain / Total hours on type:
608.00
Aircraft flight hours:
8773
Circumstances:
During an instrument approach, upon descending to the prescribed minimum descent altitude, about 1/2 mile from the missed approach point, the pilot failed to maintain flying airspeed. The airplane stalled, rolled left, and in an uncontrolled descent collided with a commercial building 0.96 nm from the runway's displaced threshold. The accident occurred during the return portion of a round trip flight, while on final approach to the pilot's alternate airport due to a weather-induced diversion. Moderate intensity snow showers and freezing fog existed. During the initial approach, the reported visibility was 1 1/2 miles. About the time the pilot passed the final approach fix, the visibility decreased to 1/2 mile, but the pilot was not informed of the decrease below his 1-mile minimum requirement. The pilot had maintained the recommended 140-knot approach speed in the icing conditions until about 3 1/2 miles from the runway. Thereafter, the airplane's speed gradually decreased until reaching about 75 knots. After the airplane started vibrating, the pilot increased engine power, but his action was not timely enough to avert stalling. Company mechanics maintained the airplane. On previous occasions overheat conditions had occurred wherein the environmental ducting melted and heat was conducted to the adjacent pneumatic tube that provides deice air to the empennage boots. During the accident investigation, the deice tube was found completely melted closed, thus rendering all of the empennage deice boots dysfunctional.
Probable cause:
The pilot's inadequate approach airspeed for the existing adverse meteorological conditions followed by his delayed remedial action to avert stalling and subsequent loss of airplane control. Contributing factors were the pilot's reduced visibility due to the inclement weather and the icing conditions.
Final Report:

Crash of an Antonov AN-26 in Heglig

Date & Time: Feb 27, 2002 at 0915 LT
Type of aircraft:
Operator:
Registration:
ST-MGL
Survivors:
Yes
Schedule:
Khartoum - Heglig
MSN:
97 09
YOM:
1980
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a charter flight from Khartoum to Heglig on behalf of an oil company, carrying 12 passengers and four crew members. On final approach in good weather conditions, the aircraft was too low and struck the ground short of runway 34 threshold. The aircraft bounced then landed hard, causing the undercarriage to be torn off. The aircraft slid on its belly, veered off runway and came to rest in bushes. Al 16 occupants evacuated safely while the aircraft was damaged beyond repair. Wind was gusting to 23 knots at the time of the accident.

Ground accident of a BAe 125-400B in Lanseria

Date & Time: Feb 12, 2002 at 0800 LT
Type of aircraft:
Operator:
Registration:
ZS-JBA
Flight Phase:
Survivors:
Yes
Schedule:
Lanseria – Blantyre
MSN:
25259
YOM:
1971
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7881
Captain / Total hours on type:
64.00
Copilot / Total flying hours:
13500
Copilot / Total hours on type:
18
Circumstances:
The aircraft was parked on the international departures apron at FALA, ready for a flight from FALA to Blantyre. The pilot assumed that the engineer had pressurised the hydraulic accumulator and therefore did not inspect it himself. When the passengers arrived, the pilot got in the aircraft and began the internal pre-start checks. The co-pilot removed the chocks after boarding the passengers, closed the door and then started to brief the passengers. At that moment the pilot noticed that the aircraft was rolling forward. Attempts to stop the aircraft were unsuccessful, the aircraft rolled forward, narrowly missed a hangar and a parked Bell Long-ranger helicopter next to the hangar, crossed the taxiway and finally stopped when entering a ditch between the taxiway and the runway. The pilot was the holder of a valid transport pilot’s licence and had the type endorsed in his licence. The operation of the hydraulic system was found to be satisfactory. The hand pump was used to pressurise the system after which the brakes could be applied successfully.
Probable cause:
The hydraulic system was not pressurised during the pre-flight inspection of the aircraft. The chocks were therefore removed without adequate hydraulic system pressure available.
Final Report:

Crash of a Dornier DO.28D-2 Skyservant off Los Roques

Date & Time: Feb 2, 2002 at 1435 LT
Type of aircraft:
Operator:
Registration:
YV-679C
Flight Phase:
Survivors:
Yes
Schedule:
Caracas - Los Roques
MSN:
4135
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a charter flight from Caracas to Los Roques, carrying 12 passengers and two pilots, among them seven Italian tourists. Over the Los Roques Island, the crew encountered technical problems and attempted to ditch the aircraft off Larga Island. All 14 occupants were quickly rescued while the aircraft sank by a depth of four metres and was damaged beyond repair.

Crash of a Cessna 207 Skywagon in Milford Sound: 6 killed

Date & Time: Jan 19, 2002 at 1000 LT
Operator:
Registration:
ZK-SEV
Flight Phase:
Survivors:
No
Site:
Schedule:
Te Anau - Milford Sound
MSN:
207-0204
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
635
Captain / Total hours on type:
13.00
Circumstances:
On Saturday, 19 January 2002, at 0931, ZK-SEV, a Cessna 207, took off from Te Anau Aerodrome for Milford Sound Aerodrome. At about 1000 the aircraft collided with the side of a mountainous valley, approximately 4400 feet above sea level and 500 metres southeast of Gertrude Saddle, some 11 kilometres from Milford Sound. The pilot and 5 passengers on board died in the collision. The aircraft probably had not reached a suitable altitude to safely cross over Gertrude Saddle, and the pilot probably left his decision too late to turn back in the valley in order to gain more height.
Probable cause:
Findings:
Findings and safety recommendations are listed in order of development and not in order of priority.
- The pilot was appropriately qualified, fit and authorised to conduct the flight.
- The aircraft records indicated the aircraft was properly maintained and airworthy. The aircraft was appropriate for the purpose and was approved for air transport operations.
- The weather conditions were suitable for the flight.
- The aircraft was probably too low to safely cross Gertrude Saddle, and the pilot probably elected to use his escape option of a left reverse turn after recognising that he would be unable to safely cross the saddle. This was left too late to safely complete the manoeuvre.
- Had the aircraft reached a suitable height to safely cross Gertrude Saddle prior to entering Gertrude Valley, the accident may have been averted.
- The pilot may have misjudged the strength of the tailwind and thus the aircraft ground speed, and the strength of any downdraughts, as he approached Gertrude Saddle. Consequently, the
closing speed with the saddle and the low height of the aircraft may have caught the pilot by surprise.
- The pilot’s delayed action in initiating a reverse turn away from Gertrude Saddle was probably a prime contributing factor to the accident.
- Pilot inexperience may have contributed to the accident.
- The current aeroplane pilot training requirements are not sufficient to ensure pilots are suitably equipped to handle the demanding flying challenges that mountainous environments can present.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Beef Island

Date & Time: Jan 18, 2002 at 1440 LT
Type of aircraft:
Operator:
Registration:
N616GL
Flight Phase:
Survivors:
Yes
Schedule:
Tortola - Tortola
MSN:
616
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On January 18, 2002 at 1440 eastern standard time, a Britten-Norman BN2-A, N616GL, operated by Fly BVI Inc,. under the provision Title 14 CFR Part 135, as a sightseeing flight, ditched off Beef Island, British Virgin Islands, following a loss of engine power on both engines. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was substantially damaged. The air transport pilot and his passengers were not injured. The flight departed Beef Island, British Virgin Islands, at 1400. According to the pilot, during a sightseeing tour the airplane experience a total loss of power on both engines at the same time. The pilot contacted the Beef Island control tower and declared an emergency and gave his position report. He then stated his intentions to ditch the airplane off the coast of Beef Island, British Virgin Islands. The airplane came to rest in six feet of water near the shoreline. During the examination of the airplane by personnel from the Department of Civil Aviation, British Virgin Islands, approximately 23 gallons of fuel were discovered in each fuel tank.

Crash of a Fairchild-Hiller FH-227C on Mt El Tigre: 26 killed

Date & Time: Jan 17, 2002 at 1101 LT
Type of aircraft:
Operator:
Registration:
HC-AYM
Flight Phase:
Survivors:
No
Site:
Schedule:
Quito – Nueva Loja
MSN:
511
YOM:
1966
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
26
Captain / Total flying hours:
17709
Captain / Total hours on type:
8338.00
Copilot / Total flying hours:
12229
Copilot / Total hours on type:
6066
Aircraft flight hours:
29154
Aircraft flight cycles:
45178
Circumstances:
The twin engine aircraft departed Quito-Mariscal Sucre Airport at 1038LT on a charter flight to Nueva Loja-Lago Agrio Airport, carrying 21 oil workers and and five crew members on behalf of the Texaco Oil Company. While cruising under VFR mode at an altitude of 15,500 feet, the crew was instructed by ATC to change heading to 094° in order to descent to Nueva Loja for a landing on runway 23. But the crew failed to comply with this instruction and continued straight ahead. Few minutes later, the crew started the descent in foggy conditions when the aircraft struck the slope of Mt El Tigre located in the south part of Colombia, near the border with Ecuador. The wreckage was found three days later at an altitude of 4,500 metres. The aircraft disintegrated on impact and all 26 occupants were killed.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the crew suffered a loss of situational awareness since their attention was focused on aspects that were not related to the flight being executed and therefore neglecting the primary function of flight which is the control of the aircraft and decision making.
The following contributing factors were identified:
- The crew failed to maintain a sterile cockpit situation,
- The crew was continuously distracted during the flight,
- Lack of technical documentation in the CIA that supports the operation,
- Lack of crew training about Crew Resources Management, human factors and Control Flight Into Terrain(CFIT),
- The weather conditions at the time of the accident on Mt El Tigre made it impossible for the crew to see the mountain,
- The aircraft was not equipped with a Ground Proximity Warning System (GPWS).
Final Report: