Crash of a Rockwell 681BT Turbo Commander in São Paulo: 7 killed

Date & Time: Dec 16, 2000 at 2120 LT
Registration:
PT-IEE
Flight Phase:
Survivors:
No
Site:
Schedule:
São Paulo – Maringá
MSN:
681-6071
YOM:
1972
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Captain / Total flying hours:
5000
Captain / Total hours on type:
600.00
Copilot / Total flying hours:
2500
Copilot / Total hours on type:
200
Circumstances:
After takeoff from runway 17 at São Paulo-Congonhas Airport, the crew was cleared to climb to 5,500 feet maintaining heading 270. Weather conditions were poor with clouds, atmospheric turbulences and strong winds. At an altitude of 5,300 feet, the aircraft lost height and descended to 4,700 feet, an altitude that was maintained for 17 seconds. Then the aircraft entered an uncontrolled descent and crashed in four houses located in the district of Vila Anhanguera, about 5,5 km southwest of the airport. The aircraft and all four houses were destroyed. All seven occupants were killed while on the ground, six people were injured, one seriously.
Probable cause:
The accident occurred in poor weather conditions. It was determined that during initial climb, the aircraft's attitude, speed and altitude varied suddenly and rapidly, causing the pilot flying a stressful situation insofar as he believed that artificial horizons presented technical problems. In such a situation, investigators consider probable the hypothesis that the pilot made inadequate corrections, exacerbating the abnormal situation in which he was operating. The following contributing factors were identified:
- The crew were suffered fatigue because they had been on duty for more than 15 hours and were unable to observe satisfactory rest time at Congonhas airport,
- This fatigue certainly affected the pilots in their decision-making,
- The urge to return home and distrust of instruments in difficult flight conditions seriously compromised the performance of pilots and their ability to make decisions,
- A direct contact with passengers was stressful as they were going through a period of mourning and were eager to return home to Maringá,
- Weather conditions were unfavorable and contributed to the anxiety of the crew,
- Poor assessment of these conditions by the pilots,
- The working time of the pilots exceeded the limitations and the operator did not take into account adequate rest conditions for the crew,
- The training of the captain in instrument flights in recent months was insufficient.
Final Report:

Crash of an Antonov AN-26 near Mona Quimbundo: 49 killed

Date & Time: Oct 31, 2000 at 1930 LT
Type of aircraft:
Registration:
D2-FDI
Flight Phase:
Survivors:
No
Schedule:
Lucapa – Dundo – Saurimo – Luanda
MSN:
120 09
YOM:
1982
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
49
Circumstances:
The aircraft departed Saurimo on a flight to Luanda, carrying 44 passengers and a crew of five. This was the last leg of day after two previous flights from Lucapa and Dundo. About 20 minutes into the flight, while in cruising altitude, the aircraft was hit by a surface-to-air missile, entered an uncontrolled descent and crashed in an open field located near Mona Quimbundo. The wreckage was found about 50 km southwest of Saurimo and all 49 occupants were killed.
Probable cause:
Shot down by a surface-to-air missile. The hostile action was claimed by UNITA rebels because the aircraft was carrying a load of diamonds stolen on their territory.

Crash of a Convair CV-580 in La Grande-4

Date & Time: Sep 27, 2000 at 1038 LT
Type of aircraft:
Operator:
Registration:
C-GFHH
Survivors:
Yes
Schedule:
Montreal – Rouyn – La Grande-3 (LG-3) – La Grande-4 (LG-4) – Montreal
MSN:
109
YOM:
1953
Flight number:
APZ180
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15500
Captain / Total hours on type:
6000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
4000
Aircraft flight hours:
78438
Circumstances:
The Hydro-Québec Convair 340 (580), registration C-GFHH, serial number 109, with 18 passengers and 4 crew members on board, made an instrument flight rules flight from La Grande 3 to La Grande 4, Quebec. The aircraft touched down on the snow-covered runway at La Grande 4 approximately 800 feet beyond the runway threshold. Shortly after the nose wheel touched down and the pilot set the propellers to reverse pitch, the aircraft drifted to the right. Despite the attempts of the pilot flying (the captain) to correct, the aircraft continued its course and exited the south side of Runway 09 at approximately 50 knots. The aircraft travelled 350 feet over soft, rocky ground and came to rest about 120 feet outside the runway edge, about 2500 feet from the runway threshold. The flight crew followed the procedure to shut down the engines, but the left engine would not stop. On the captain's order, the first officer went into the passenger cabin and ordered an evacuation. All passengers exited the aircraft via the window emergency exits over the right wing. The left engine eventually shut down on its own after about 15 minutes. Five persons sustained minor injuries. The aircraft sustained substantial damage but did not catch fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The steering control valve lever was not reassembled in accordance with the specifications and the drawings in the overhaul manual and the maintenance manual: the lever was assembled with two washers instead of one, and the circumference of the bushing was 0.0005 inch greater than the circumference of the hole in the lever. These two deficiencies created additional resistance that
impeded the pivoting of the aircraft steering wheel.
2. The nylon locknuts were reinstalled during the repair of the steering control valve, contrary to the recommendation that they be used only once. The locknuts then came loose in service, creating play in the parts of the valve.
3. Incorrect interpretation of the problem and the influence of previous experience using the nose-gear steering wheel led the crew to make the flight despite their concern about the aircraft's nose-gear steering system.
Findings as to Risk:
1. The maintenance personnel of Precision Aero Components Inc. used the (incomplete) maintenance manual instead of the overhaul manual to overhaul and repair the steering control valve,
contributing to the incorrect reassembly of the valve.
2. The steering control valve lever was not fitted with a grease fitting, and the outside of the bushing was not grooved to allow adequate lubrication, thereby risking corrosion and seizure of the bushing inside the lever.
3. The limited experience and the lack of formal training of the maintenance personnel concerning the repair and the overhaul on the steering control valve might have contributed to the incorrect
reassembly of the steering control valve.
4. The pilot flying cut the electrical power, as required by the hard landing procedure. The left engine could therefore not be shut down, causing a risk of injury when the passengers evacuated.
5. The pilot flying cut the electrical power after the aircraft exited the runway, as required by the hard landing procedure. The electrical power required to operate the public address and alarm systems was thereby lost, and the evacuation could not be ordered promptly.
6. The evacuation slide automatic deployment system was inadvertently deactivated, which could have delayed the evacuation and compromised passenger safety.
7. After separating from the engine, the left propeller blades entered the fuselage and damaged an unoccupied seat.
Other Findings:
1. The numerous changes in ownership of the Convair type certificate and the lack of technical support from the current holder caused maintenance problems for Convair operators and approved
maintenance organizations (AMOs), particularly for recently established AMOs.

Crash of a Piper PA-31T3-T1040 Cheyenne in Nuiqsut: 5 killed

Date & Time: Sep 18, 2000 at 1510 LT
Type of aircraft:
Operator:
Registration:
N220CS
Survivors:
Yes
Schedule:
Deadhorse – Nuiqsut
MSN:
31-8275013
YOM:
1982
Flight number:
6C181
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
2517
Captain / Total hours on type:
165.00
Aircraft flight hours:
10157
Circumstances:
The airline transport certificated pilot was landing at a remote village on a scheduled domestic commuter flight with nine passengers. The accident airplane, a twin-engine turboprop certified for single-pilot operations, was equipped with a fuselage-mounted belly cargo pod. Witnesses saw the airplane touch down on the gravel runway with the landing gear retracted. The belly pod lightly scraped the runway for about 40 feet before the airplane transitioned to a climb. The propeller tips did not contact the runway. As the airplane began climbing away from the runway, the landing gear was extended. The airplane climbed to about 100 to 150 feet above the ground, and then began a descending left turn, colliding with tundra-covered terrain. A postcrash fire destroyed the fuselage, right wing, and the right engine. The flaps were found extended to 40 degrees. The balked landing procedure for the airplane states, in part: "power levers to maximum, flaps to 15 degrees, landing gear up, and then retract the flaps." Five passengers seated in the rear of the airplane survived the crash. The survivors did not recall hearing a gear warning horn before ground contact. The airplane was landed gear-up eight months before the accident. The airplane was nearly landed gear-up four months before the accident. Each time, a landing gear warning horn was not heard by the pilot or passengers. A postcrash examination of the airplane and engines did not locate any preimpact mechanical malfunction. The FAA's Fairbanks, Alaska, FSDO conducted an inspection of the operator six months before the accident, and recommended the operator utilize two pilots in the accident airplane. Following the accident, the Fairbanks FSDO required the operator to utilize two pilots for passenger flights in the accident airplane make and model.
Probable cause:
The pilot's failure to extend the landing gear, his improper aborted landing procedure, and inadvertent stall/mush. Factors in the accident were an improper adjustment of the landing gear warning horn system by company maintenance personnel, and the failure of the pilot to utilize the pre-landing checklist.
Final Report:

Crash of a Beechcraft 200 Super King Air in Wernadinga Station: 8 killed

Date & Time: Sep 4, 2000 at 1510 LT
Operator:
Registration:
VH-SKC
Flight Phase:
Survivors:
No
Schedule:
Perth - Leonora
MSN:
BB-47
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2053
Captain / Total hours on type:
138.00
Aircraft flight hours:
18771
Circumstances:
On 4 September 2000, a Beech Super King Air 200 aircraft, VH-SKC, departed Perth, Western Australia at 1009 UTC on a charter flight to Leonora with one pilot and seven passengers on board. Until 1032 the operation of the aircraft and the communications with the pilot appeared normal. However, shortly after the aircraft had climbed through its assigned altitude, the pilot’s speech became significantly impaired and he appeared unable to respond to ATS instructions. Open microphone transmissions over the next 8-minutes revealed the progressive deterioration of the pilot towards unconsciousness and the absence of any sounds of passenger activity in the aircraft. No human response of any kind was detected for the remainder of the flight. Five hours after taking off from Perth, the aircraft impacted the ground near Burketown, Queensland, and was destroyed. There were no survivors.
Probable cause:
Due to the limited evidence available, it was not possible to draw definitive conclusions as to the factors leading to the incapacitation of the pilot and occupants of VH-SKC.
The following findings were identified:
1. The pilot was correctly licensed, had received the required training, and there was no evidence to suggest that he was other than medically fit for the flight.
2. The weather conditions on the day presented no hazard to the operation of the aircraft on its planned route.
3. The flightpath flown was consistent with the aircraft being controlled by the autopilot in heading and pitch-hold modes with no human intervention after the aircraft passed position DEBRA.
4. After the aircraft climbed above the assigned altitude of FL250, the speech and breathing patterns of the pilot, evidenced during the radio transmissions, displayed changes consistent with hypoxia.
5. Testing revealed that Carbon Monoxide and Hydrogen Cyanide were highly unlikely to have been factors in the occurrence.
6. The low Carbon Monoxide and Cyanide levels, and the absence of irritation in the airways of the occupants indicated that a fire in the cabin was unlikely.
7. The incapacitation of the pilot and passengers was probably due to hypobaric hypoxia because of the high cabin altitude and their not receiving supplemental oxygen.
8. A rapid or explosive depressurisation was unlikely to have occurred.
9. The reasons for the pilot and passengers not receiving supplemental oxygen could not be determined.
10. Setting the visual alert to operate when the cabin pressure altitude exceeds 10,000 ft and incorporating an aural warning in conjunction with the visual alert, may have prevented the accident.
11. The training and actions of the air traffic controller were not factors in the accident.
Significant factors:
1. The aircraft was probably unpressurised for a significant part of its climb and cruise for undetermined reasons.
2. The pilot and passengers were incapacitated, probably due to hypobaric hypoxia, because of the high cabin altitude and their not receiving supplemental oxygen.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Hilo: 1 killed

Date & Time: Aug 25, 2000 at 1735 LT
Operator:
Registration:
N923BA
Survivors:
Yes
Schedule:
Kona – Kona
MSN:
31-8252024
YOM:
1982
Flight number:
BIA057
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2067
Captain / Total hours on type:
465.00
Aircraft flight hours:
3492
Circumstances:
The pilot ditched the twin engine airplane in the Pacific ocean after experiencing a loss of engine power and an in-flight engine fire while in cruise flight. The flight was operating at 1,000 feet msl, when the pilot noticed a loss of engine power in the right engine. At the same time the pilot was noticing the power loss, passengers noted a fire coming from the right engine cowling. The pilot secured the right engine and feathered the propeller. He attempted to land the airplane at a nearby airport; however, when he realized that the airplane was unable to maintain altitude he elected to ditch the airplane in the ocean. Prior to executing the forced landing, the pilot instructed the passengers to don their life jackets and assume the crash position. After touchdown, all but one passenger exited the airplane through the main cabin and pilot doors. It was reported that the remaining passenger was frightened, and could not swim. One survivor saw the remaining passenger sitting in the seat with the seat belt still secured and the life vest inflated. The pilot and passengers were then rescued from the ocean via rescue helicopter and boat. Postaccident examination of the airplane revealed that the right engine's oil converter plate gasket had deteriorated and extruded from behind the converter plate, allowing oil to spray in the accessory section and resulting in the subsequent engine fire. The engine manufacturer had previously issued a mandatory service bulletin (MSB) requiring inspection of the gasket every 50 hours for evidence of gasket extrusion around the cover plate or oil leakage. Maintenance records revealed that the inspection had been conducted 18.3 hours prior to the accident. At the time of the accident, the right engine had accumulated 386.8 hours since its last overhaul, and gasket replacement. The MSB was issued one month prior to the accident, after the manufacturer received reports of certain oil filter converter plate gaskets extruding around the oil filter converter plate. The protruding or swelling of the gasket allowed oil to leak and spray from between the plate and the accessory housing. A series of tests were conducted on exemplar gaskets by submerging them in engine oil heated to 245 degrees F; after about 290 hours, the gasket material displayed signs of deterioration similar to that of the accident gasket. A subsequent investigation revealed that the engine manufacturer had recently changed gasket suppliers, which resulted in a shipment of gaskets getting into the supply chain that did not meet specifications. As a result of this accident, the engine manufacturer revised the MSB to require the replacement of the gasket every 50 hours. The FAA followed suit and issued an airworthiness directive to mandate the replacement of the gasket every 50 hours.
Probable cause:
Deterioration and failure of the oil filter converter plate gasket, which resulted in a loss of engine power and a subsequent in-flight fire.
Final Report:

Crash of a Cessna 207 Skywagon in San Juan de Manapiare: 3 killed

Date & Time: Aug 23, 2000 at 0703 LT
Registration:
YV-753C
Survivors:
Yes
Schedule:
Puerto Ayacucho – San Juan de Manapiare
MSN:
207-0344
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On final approach to San Juan de Manapiare Airport in bad weather conditions, the single engine aircraft crashed on hilly terrain. The pilot and two passengers were killed while three other occupants were injured.

Crash of a Piper PA-31-350 Navajo Chieftain in Hazlehurst: 3 killed

Date & Time: Aug 15, 2000 at 0825 LT
Operator:
Registration:
N801MW
Survivors:
No
Schedule:
Dothan - Hazlehurst
MSN:
31-8152136
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6400
Circumstances:
The flight was cleared for an NDB or GPS runway 14 instrument approach. The pilot was instructed to report procedure turn. Center radar reported the airplane's altitude was last observed at 200 feet. A witness observed the airplane as it collided with trees and the ground and, subsequently burst into flames. No mechanical problem with the airplane was reported by the pilot or discovered during the wreckage examination. Weather minimums for the approach are 800 feet an one mile. Low clouds were reported in the area at the time of the accident.
Probable cause:
Pilot's failure to follow instrument procedures and descended below approach minimums and collided with trees. A factor was low clouds.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Burlington: 9 killed

Date & Time: Aug 9, 2000 at 0752 LT
Registration:
N27944
Flight Phase:
Survivors:
No
Site:
Schedule:
Lakehurst - Patuxent
MSN:
31-7952056
YOM:
1979
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Captain / Total flying hours:
3968
Captain / Total hours on type:
1418.00
Circumstances:
A Piper PA-31-350 Navajo Chieftain, N27944, operated by Patuxent Airways, Inc., Hollywood, Maryland, and a Piper PA-44-180 Seminole, N2225G, operated by Hortman Aviation Services, Inc., Philadelphia, Pennsylvania, were destroyed when they collided in flight over Burlington Township, New Jersey. The airline transport pilot, commercial pilot, and seven passengers aboard the Navajo Chieftain were killed, as were the flight instructor and the private pilot aboard the Seminole. Day visual meteorological conditions existed at the time of the accident, and both airplanes were operating under visual flight rules when the collision occurred. The flight crews of both airplanes were properly certificated and qualified in accordance with applicable Federal regulations. None of these individuals was experiencing any personal problems or rest anomalies that would have affected their performance. The airplanes had undergone the required inspections. Examination of their maintenance documents revealed that both airplanes complied with all appropriate airworthiness directives. Evidence gathered from the wreckage indicated that neither airplane had experienced an in-flight fire, bird strike, or structural or mechanical failure. Tissue samples revealed that the pilot of the Seminole had taken doxylamine sometime before the accident. (Doxylamine is a sedating antihistamine that has substantial adverse effects on performance.) However, the amount of blood available for analysis was insufficient for determining exactly when the pilot may have ingested the medication or whether his performance was impaired by the effects of doxylamine. A partial cockpit visibility study revealed that the Seminole would have been visible to the pilots in the Chieftain for at least the 60 seconds before the collision. No stereo photographs from a Seminole cockpit were available to determine precise obstruction angles. However, because of the relative viewing angle, the Chieftain would have been visible to the pilots in the Seminole for most of the last 60 seconds. The study further revealed that about 4 seconds before impact, or about .11 nm separation, the angular width of each airplane in each pilot's field of vision would have been approximately 0.5 to 0.6 degrees or about 1/4 inch apparent size at the windscreen.
Probable cause:
The failure of the pilots of the two airplanes to see and avoid each other and maintain proper airspace separation during visual flight rules flight.
Final Report:

Crash of a De Havilland DHC-3 Otter in Lake Stevens

Date & Time: Aug 2, 2000
Type of aircraft:
Operator:
Registration:
C-FMAJ
Flight Phase:
Survivors:
Yes
MSN:
383
YOM:
1960
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A DHC-3 and a Cessna 185 (both float equipped aircraft) had been chartered to move equipment from an outpost camp which was being threatened by forest fires in the Tadoule Lake (Lac Brochet, MB) area. Takeoff was conducted in a westerly direction into light winds estimated to be 5 to 8 knots. Besides the pilot there were two passengers (the camp owner and his son), two 45 gallon drums of #2 gas, a propane cylinder, battery chargers plus other sundry items. It was reported that once the aircraft was airborne, a windshift occurred which may have resulted in rollover and a downdraft situation. The aircraft began to descend, despite the application of full engine power, and settled into the trees with little forward speed and the wings in a near level attitude. The aircraft was then consumed by fire, the pilot and his two passengers were able to escape with minor scrapes and bruises. The pilot of the Cessna 185 witnessed the accident while airborne and he then returned and landed and rendered assistance to the three occupants. The local temperature was 27 degrees C, and the aircraft was near its maximum gross weight. It was reported that the aircraft had a headwind in proximity to the forest fire on takeoff, and that it flew into the area of a tailwind during initial climb.