Crash of a Cessna 404 Titan II in Glasgow: 8 killed

Date & Time: Sep 3, 1999 at 1236 LT
Type of aircraft:
Registration:
G-ILGW
Flight Phase:
Survivors:
Yes
Schedule:
Glasgow – Aberdeen
MSN:
404-0690
YOM:
1980
Flight number:
Saltire 3W
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4190
Captain / Total hours on type:
173.00
Copilot / Total flying hours:
2033
Copilot / Total hours on type:
93
Aircraft flight hours:
6532
Circumstances:
The aircraft had been chartered to transport an airline crew of nine persons from Glasgow to Aberdeen. The aircraft was crewed by two pilots and, so far as could be determined, its take-off weight was between 8,320 and 8,600 lb. The maximum permitted take-off weight was 8,400 lb. ATC clearance for an IFR departure was obtained before the aircraft taxied from the business aviation apron for take-off from runway 23, with a take-off run available of 2,658 metres. According to survivors, the take-off proceeded normally until shortly after the aircraft became airborne when they heard a thud or bang. The aircraft was then seen by external witnesses at low height, to the left of the extended runway centerline, in a wings level attitude that later developed into a right bank and a gentle descent. Witnesses reported hearing an engine spluttering and saw at least one propeller rotating slowly. There was a brief 'emergency' radio transmission from the commander and the aircraft was seen entering a steep right turn. It then entered a dive. A witness saw the wings levelled just before the aircraft struck the ground on a northerly track. Three survivors were helped from the wreckage by a nearby farm worker before flames from a severe post-impact fire engulfed the cabin.
Probable cause:
The following causal factors were identified:
- The left engine suffered a catastrophic failure of its accessory gear train leading to a progressive but complete loss of power from that engine,
- The propeller of the failed engine was not feathered and therefore the aircraft was incapable of climbing on the power of one engine alone,
- The commander feathered the propeller of the right-hand engine, which was mechanically capable of producing power resulting in a total loss of thrust,
- The commander attempted to return to the departure airfield but lost control of the aircraft during a turn to the right.
Final Report:

Crash of a Cessna 404 Titan II on Mt Meru: 12 killed

Date & Time: Sep 1, 1999 at 1026 LT
Type of aircraft:
Operator:
Registration:
5H-NAT
Flight Phase:
Survivors:
No
Site:
Schedule:
Seronera Lodge - Kilimanjaro
MSN:
404-0805
YOM:
1981
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
16500
Captain / Total hours on type:
2000.00
Circumstances:
Two Cessna 404 Titan II operated by Northern Air departed Seronera Lodge in the mid morning on a charter flight to Kilimanjaro Airport, carrying a total of 18 US tourists and two pilots (7 passengers and one pilot in the first aircraft and 11 passengers and one pilot in the second aircraft). The passengers should be later transferred from Kilimanjaro to Nairobi with an Air Kenya aircraft. After takeoff, the pilot in the first Cessna warned the second pilot about the lack of visibility in the area. While cruising in marginal weather conditions at an altitude of 8,770 feet, the second aircraft struck the southern slope of Mt Meru (4,565 metres high). The wreckage was found the following day at an altitude of 2,833 metres. The aircraft was destroyed by impact forces and all 12 occupants were killed.
Probable cause:
Controlled flight into terrain after the pilot failed to maintain the minimum safe altitude for the area of Mt Meru. It was determined that the pilot informed his colleague he wanted to maintain FL110 at a distance of 53 km from the first beacon but for unknown reasons, he was maintaining an insufficient altitude of 9,500 feet at a distance of 45 km from the first beacon. Investigations were unable to determine the reason why the pilot was unable to maintain the minimum safe altitude. Poor weather conditions with low clouds and drizzle was a contributing factor.
Final Report:

Crash of a BAe 125-600A in Las Vegas

Date & Time: Aug 17, 1999 at 1817 LT
Type of aircraft:
Operator:
Registration:
N454DP
Survivors:
Yes
Schedule:
Salina - Las Vegas
MSN:
256044
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10000
Captain / Total hours on type:
275.00
Copilot / Total flying hours:
5300
Copilot / Total hours on type:
700
Aircraft flight hours:
5753
Circumstances:
The pilot landed with the landing gear in the retracted position, when both the main and auxiliary hydraulic systems failed to extend the gear. The airplane caught fire as it skidded down the runway. The left inboard main tire had blown on takeoff and a 30-inch section of tread was loose. Black marks were along the length of the landing gear strut and up into the wheel well directly above the left inboard wheel. The normal and emergency hydraulic systems both connect to a common valve body on the landing gear actuator. This valve body also had black marks on it. A gap of 0.035 inch was measured between the valve body and actuator. When either the normal or auxiliary hydraulic system was pressurized, red fluid leaked from this gap. Examination revealed that one of two bolts holding the hydraulic control valve in place had fractured and separated. The fractured bolt experienced a shear load that was oriented along the longitudinal axis of the actuator in a plane consistent with impact forces from the flapping tire tread section.. Separation of only one bolt allowed the control valve to twist about the remaining bolt in response to the load along the actuator's longitudinal axis. This led to a loss of clamping force on that side of the actuator. Hydraulic line pressure lifted the control valve, which resulted in rupture of an o-ring that sealed the hydraulic fluid passage. 14 CFR 25.739 describes the requirement for protection of equipment in wheel wheels from the effects of tire debris. The revision of this regulation in effect at the time the airplane's type design was approved by the FAA requires that equipment and systems essential to safe operation of the airplane that is located in wheel wells must be protected by shields or other means from the damaging effects of a loose tire tread, unless it is shown that a loose tire tread cannot cause damage. Examination of the airplane and the FAA approved production drawings disclosed that no shields were installed to protect the hydraulic system components in the wheel well.
Probable cause:
The complete failure of all hydraulic systems due to the effects of a main gear tire disintegration on takeoff. Also causal was the manufacturer's inadequate design of the wheel wells, which did not comply with applicable certification regulations, and the FAA's failure to ensure that the airplane's design complied with standards mandated in certification regulations.
Final Report:

Crash of a Cessna 414 Chancellor in Monrovia: 6 killed

Date & Time: Aug 10, 1999 at 2005 LT
Type of aircraft:
Registration:
N373BC
Survivors:
No
Schedule:
Harper - Monrovia
MSN:
414-0411
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The twin engine aircraft departed Harper on a charter flight to Monrovia, carrying five police officers and one pilot. On a night approach to Monrovia-Roberts Airport, the aircraft crashed in unknown circumstances 4 km short of runway. The aircraft was destroyed and all six occupants were killed.

Crash of a Beechcraft C90 King Air in Munson: 2 killed

Date & Time: Jun 25, 1999 at 1014 LT
Type of aircraft:
Operator:
Registration:
N3019W
Flight Phase:
Survivors:
No
Schedule:
Zephyrhills – Mobile
MSN:
LJ-639
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7000
Aircraft flight hours:
3965
Circumstances:
The pilot received a preflight weather briefing and was advised of thunderstorms with tops to 45,000 feet along a portion of the route of flight. En route, the pilot was advised of significant areas of heavy precipitation to which the pilot responded, 'uh roger one nine whiskey it looks like on our radar here that uh we go straight ahead we'll be all right there.' The flight was cleared to descend to 11,000 feet and the pilot requested deviation to the right for weather avoidance. The pilot made several routine radio communications while descending at a calculated average rate of descent of approximately 2,571 fpm before encountering adverse weather. During this time while descending, the calculated calibrated airspeed increased from approximately 190 knots to approximately 265 knots (the design dive speed Vd). The flight encountered a level 5 weather echo then began a high rate of descent. Both horizontal stabilizers with elevators and both outer portions of both wings failed in a down direction. Examination of the flight control cables, fracture surfaces of the wings and horizontal stabilizers, engines, and propellers revealed no evidence of preimpact failure or malfunction. The pilot did not request pilot reports. The design maneuvering speed of the airplane is 169 knots indicated; the POH indicates to slow to this speed for turbulence penetration.
Probable cause:
The poor in-flight weather evaluation by the pilot-in-command and his operation of the airplane at an indicated airspeed greater than the design maneuvering speed (Va) in a thunderstorm contrary to the pilot's operating handbook resulting in an in-flight breakup. A contributing factor in the accident was the failure of the pilot to obtain in-flight weather advisories with any air traffic control facility before encountering the adverse weather.
Final Report:

Crash of a Beechcraft A100 King Air in Thunder Bay

Date & Time: Jun 14, 1999 at 1038 LT
Type of aircraft:
Operator:
Registration:
C-GASW
Flight Phase:
Survivors:
Yes
Schedule:
Thunder Bay – Red Lake
MSN:
B-108
YOM:
1972
Flight number:
THU103
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Thunder Airlines Limited Beech A100 King Air aircraft, serial number B108, took off at 1034 eastern daylight saving time (EDT) on a charter flight from Thunder Bay, Ontario, for Red Lake, Ontario, with two pilots and three passengers on board. After getting airborne, the aircraft pitched up to approximately 70 degrees, reaching a height estimated to be between 500 and 700 feet above ground level. It then rolled to the left, pitched steeply nose-down, and descended to the ground within the confines of the airport. The aircraft contacted the soft, level ground in a relatively level attitude and covered a distance of about 500 feet before coming to rest in a wooded area immediately beyond an elevated railroad bed and track. The cabin remained intact during the crash sequence, and all occupants escaped without any injuries. The aircraft was damaged beyond repair. An ensuing fuel-fed fire was rapidly extinguished by airport emergency response services (ERS)
personnel.
Probable cause:
The flight crew lost pitch control of the aircraft on take-off when the stabilizer trim actuators became disconnected because they had not been properly reinstalled by the AME during maintenance work conducted before the flight. The crew chief responsible for the inspection did not ensure correct assembly of the stabilizer trim actuators, which contributed to the accident.
Final Report:

Crash of a De Havilland DHC-3 Otter near Points North Landing

Date & Time: May 1, 1999
Type of aircraft:
Operator:
Registration:
C-FASV
Flight Phase:
Survivors:
Yes
MSN:
23
YOM:
1953
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
20000
Captain / Total hours on type:
6400.00
Circumstances:
The wheel-ski equipped de Havilland DHC-3 Otter, C-FASV, serial number 23, was engaged in flying road construction crews from base camps to work sites in northern Saskatchewan. A five-man crew was moved from a base camp to a small lake, about 22 nautical miles (nm) from Points North Landing, Saskatchewan, the company's main base. The drop-off was made in the morning with a pick-up planned for late afternoon. The pilot then flew back to Points North Landing and filled the aircraft's fuel tanks from the company's main fuel supply. When the pilot returned for the pick-up, the ambient temperature was about seven degrees Celsius, and there were between five and six inches of slush on the ice surface. The pilot loaded the passengers and attempted a take-off. The aircraft accelerated slowly in the slush, and the pilot rejected the take-off. He selected a different take-off run, moved a passenger to a forward seat, and attempted a second take-off. The pilot continued beyond his previously selected rejection distance. The engine revolutions per minute (rpm) then reportedly decreased by about 150 rpm. The aircraft did not become airborne, and it ran into the low shoreline and crashed, skidding to a stop about 300 feet from the shore. An intense fire broke out immediately. The passengers and pilot evacuated the aircraft. Only one passenger suffered minor burns during the evacuation. Flames engulfed the main fuselage and engine, destroying the aircraft.
Probable cause:
The pilot continued the take-off run with the left ski firmly adhering to the slushy surface beyond a point at which a reject could have been made safely. Contributing to the occurrence was the decrease in engine rpm during take-off.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 200 in Palm Beach

Date & Time: Apr 5, 1999 at 0945 LT
Operator:
Registration:
N838MA
Survivors:
Yes
Schedule:
Palm Beach - Kissimmee
MSN:
188
YOM:
1968
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8000
Captain / Total hours on type:
200.00
Aircraft flight hours:
16659
Circumstances:
The pilot reported that prior to takeoff, he completed a preflight inspection of the airplane that included checking the engine oil quantity. The line personnel topped off the oil reservoirs, and reportedly secured the engine oil reservoir filler caps. Approximately two minutes into the flight, the right engine oil pressure warning light illuminated. The pilot informed Palm Beach Approach Control of the engine oil pressure problem, shut down the right engine, and returned to Lantana. As the flight approached runway 03, the pilot heard a radio transmission from another airplane taxiing for takeoff. As the pilot continued the approach, with full flaps extended, he elected to go-around 1500 feet from the approach end of the 3000-foot runway. The airplane collided with the ground during the go-around maneuver to runway 15. The wreckage examination also disclosed that the right cowling showed oil streaming back from behind the engine and onto the wing strut. Inspection of the oil filler cap revealed that it had not been properly installed.
Probable cause:
The pilot's failure to secure the engine oil filler cap during the preflight inspection that resulted the subsequent loss of engine power, and his in-flight decision to attempt a single engine go-around with full wing flaps extended.
Final Report:

Crash of an Airbus A300C4-620 in Rhodes

Date & Time: Mar 24, 1999 at 1210 LT
Type of aircraft:
Operator:
Registration:
A6-PFD
Survivors:
Yes
Schedule:
Dubai - Rhodes
MSN:
374
YOM:
1985
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
252
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Dubai, the crew completed the approach to Rhodes-Diagoras Airport in rain falls and strong winds. The aircraft landed at a speed of 166 knots, about 22 knots above Vref. After touchdown, the ground spoilers did not deploy automatically because they had not been armed. Consequently the auto brake system, which operates by the deployment of spoilers, did not activate. The crew attempted manual braking but this operation was too late and the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest few dozen metres further. All 271 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Douglas DC-3C near Tame: 8 killed

Date & Time: Mar 18, 1999 at 1630 LT
Type of aircraft:
Operator:
Registration:
HK-337
Flight Phase:
Survivors:
No
Site:
Schedule:
Cúcuta – Yopal
MSN:
11831
YOM:
1943
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
7838
Captain / Total hours on type:
7623.00
Copilot / Total flying hours:
1146
Copilot / Total hours on type:
940
Aircraft flight hours:
29475
Circumstances:
The twin engine aircraft departed Cúcuta-Camilo Daza Airport at 1533LT on a charter flight to Yopal, carrying five passengers, three crew members and a load of 2,500 kilos of various goods. About an hour into the flight, while cruising over the El Cocuy National Park, the aircraft encountered unfavorable currents, lost height and crashed in an isolated and mountainous area located about 45 km west of Tame. The wreckage was found on 12 April 1999 and all eight occupants were killed.
Probable cause:
Possible loss of control of the aircraft due to the presence of strong air currents or windshear, accompanied by extreme turbulences that caused the aircraft to lose height and struck the ground. Inadequate planning of the en route flight, overflying the mountain range apparently with the purpose of performing the operation in less time.
Final Report: