Crash of a Cessna 414 Chancellor in Orland

Date & Time: May 21, 1999 at 1725 LT
Type of aircraft:
Registration:
N8153Q
Flight Type:
Survivors:
Yes
Schedule:
San Jose – Redding
MSN:
414-0053
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
480.00
Aircraft flight hours:
4471
Circumstances:
The pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidly decaying altitude, and power. During the landing roll, the airplane collided with a ditch. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synthetic polymer that is used as an agricultural soil amendment that aids in reducing soil erosion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be improperly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminates with no caps or covers for protection.
Probable cause:
A loss of engine power in both engines due to fuel contamination, which resulted from the fueling facilities improper quality control procedures.
Final Report:

Crash of a Beechcraft A100 King Air in Irati

Date & Time: Apr 14, 1999 at 1200 LT
Type of aircraft:
Operator:
Registration:
PT-LZA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Foz do Iguaçu – Curitiba
MSN:
B-200
YOM:
1974
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1320
Copilot / Total hours on type:
60
Circumstances:
The crew departed Foz do Iguaçu Airport at 2215LT on a ferry flight to Curitiba. About 55 minutes into the flight, while in cruising altitude by night, the right engine failed, followed few seconds later by the left engine. The crew reduced his altitude and attempted an emergency landing when the aircraft crashed in a grassy area near Irati. While the copilot escaped uninjured, the captain was injured. The aircraft was destroyed.
Probable cause:
Failure of both engines in flight due to fuel exhaustion. The following findings were identified:
- The crew failed to prepare the flight according to published procedures,
- The crew failed to check there was sufficient fuel in tanks prior to departure,
- The crew failed to follow the pre takeoff checklist,
- The captain showed excessive self confidence
- The captain exercised pressure on the copilot,
- The crew suffered fatigue due to an excessive period of work. At the time of the accident, the crew was overduty by three hours,
- The crew consumed alcohol beverages the night before the flight.
Final Report:

Crash of a Cessna T303 Crusader near Nottingham

Date & Time: Jul 16, 1998 at 1833 LT
Type of aircraft:
Registration:
G-BSPF
Flight Type:
Survivors:
Yes
Schedule:
Sheffield – Nottingham
MSN:
303-00100
YOM:
1982
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
290
Captain / Total hours on type:
68.00
Circumstances:
The aircraft was en route from Sheffield City Airport to Nottingham where it was based. The pilot joined the traffic zone at Burton Joyce, an unofficial but well used Visual Reporting Point, at a height of about 1,000 feet. The weather was fine with good visibility and the pilot took the opportunity to view the house of the aircraft's co-owner located in the vicinity of Burton Joyce. While orbiting the house, the pilot felt a moderate 'bumping' sensation which he attributed to thermal activity rather than pre-stall buffet. The left wing suddenly dropped and the aircraft rolled through the vertical. The pilot applied corrective rudder and moved the control column forward which rolled the aircraft erect but he was unable to arrest the rate of descent because the engines did not appear to be developing full power. He therefore elected to carry out a forced landing with the landing gear retracted. On approaching the field, the aircraft struck a telegraph pole, yawed to the left and landed with a very high rate of descent before coming to a halt after a short ground slide. The pilot was unable to evacuate the aircraft because of his injuries but was rescued by local people who were quickly on the scene. There was no fire. The pilot stated that at the time the aircraft departed from normal flight, he was flying at about 100 kt with 60° of bank. The basic stalling speed of the aircraft in the configuration at the time was about 70 kt. Application of the correction for load factor in the turn would have given a stalling speed of 100 kt. The majority of eye witnesses stated that the aircraft was very low at the point at which it departed from normal flight, probably in the region of 300 feet above ground level.
Final Report:

Crash of a Rockwell Grand Commander 680 in the Atlantic Ocean: 1 killed

Date & Time: Apr 9, 1998
Operator:
Registration:
4X-CCS
Flight Phase:
Flight Type:
Survivors:
No
MSN:
680-1731-138
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, departed Southend on a ferry flight to Canada with an intermediate stop in Greenland. En route, he reported to ATC severe icing conditions. Shortly later, the aircraft entered an uncontrolled descent and crashed in the Atlantic Ocean about 167 km southeast of the Greenland coast. The pilot was killed.

Crash of a Piper PA-31-350 Navajo Chieftain on Mt Kilimandjaro: 1 killed

Date & Time: Nov 1, 1997 at 1020 LT
Operator:
Registration:
5H-AZM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nairobi - Zanzibar
MSN:
31-8052207
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Circumstances:
On 1 November 1997 at 09:46 hours 5H-AZM took off from Nairobi Wilson airport, for a visual flight rules flight to Zanzibar International Airport, Tanzania. It was carrying one pilot and some cargo. There were no passengers. The flight plan indicated that the aircraft had 0330 hours of fuel on departure. The pilot planned' to fly a direct route to Zanzibar with Dar-es-salaam International airport as his alternate aerodrome. After take off from Nairobi Wilson, the flight transited the southern axis lane of the Nairobi control Zone to the zone boundary. The pilot checked the Nairobi zone boundary with Nairobi Wilson Tower and was instructed by air traffic control to contact the Nairobi Control Centre. No contact was reported established by Nairobi Control with 5H-AZM. 5H-AZM contacted the Kilimanjaro Control Tower at 10:20 hours and passed his own ward estimates as Flight Information Region 10:25 hours and arrival at Zanzibar at 11:40 hours. 5H-AZM was advised that there was no reported traffic for the flight in the Kilimanjaro Terminal Control area at 'the VFR flight level 115, and at the same time instructed the aircraft to contact Dar-es-salaam Control on 119.6 MHz when in range. No further transmission was received from the aircraft. It also failed to arrive in Zanzibar. Unfruitful formal searches (involving communications, aerial and ground searches) were mounted on 3 November 1997 along the probable route area in Kenya and Tanzania. The formal search was terminated on 4 December 1997 and there after the missing aircraft incident was considered to be an 'accident. Wreckage was eventually located in the Kibo Crater near the summit of Mount Kilimanjaro in Tanzania on 28 August 2003, almost six years later. The wreckage of the Piper PA 31-350 was found at 15,400 feet on the Kibo wing. It was also 30 nautical miles west of its projected track. The aircraft had earlier been cleared to climb from 9,500 feet to 11,500 feet under visual flight rules.
Probable cause:
Controlled flight into terrain for unknown reasons.

Crash of a Piper PA-31-310 Navajo B in Grand Manan

Date & Time: Sep 12, 1997 at 2130 LT
Type of aircraft:
Registration:
C-FZVC
Flight Type:
Survivors:
Yes
Schedule:
Yarmouth - Grand Manan
MSN:
31-7812038
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Grand Manan, New Brunswick, at 1938 Atlantic daylight time (ADT) on a charter flight to Yarmouth, Nova Scotia, with the pilot and five passengers on board. After dropping off the passengers at Yarmouth, the aircraft departed at 2106 ADT for a night visual flight to return to Grand Manan. The pilot was unable to land at Grand Manan off the first visual approach because of low weather conditions and conducted a second visual approach. During the second approach, he noticed that he required increasing right rudder to maintain direction, and that the left engine manifold pressure was low. The pilot feathered the left propeller and, despite the application of full power on the right engine, the aircraft would not accelerate or climb. The aircraft began a shallow descent into a fog layer, and the aircraft collided with some trees, pitched nose-down, and struck the ground. The aircraft was destroyed by the impact and a post-impact fire. The pilot suffered serious injuries, but managed to get out of the aircraft and make his way to a nearby cabin where he was found by a ground search team about three hours later.
Probable cause:
The aircraft lost power on the left engine during the approach for undetermined reasons and descended into the ground. The cause of the engine power loss was not determined. The low airspeed, at the time of the engine power loss, decreased the time available to the pilot to secure the emergency in accordance with the POH, and contributed to the poor single-engine performance of the aircraft.
Final Report:

Crash of a Cessna 550 Citation II in Cocal do Sul: 2 killed

Date & Time: Aug 15, 1997 at 1925 LT
Type of aircraft:
Operator:
Registration:
PT-LML
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Porto Alegre - Rio de Janeiro
MSN:
550-0013
YOM:
1978
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On a flight from Porto Alegre to Rio de Janeiro, while cruising at an altitude of 33,000 feet, the aircraft entered an uncontrolled descent. The crew did not send any distress call. The aircraft descended with a rate of 20,000 feet per minute. At an altitude of 1,500 feet, it disintegrated in the air and eventually crashed. Both pilots were killed.
Probable cause:
It is believed that the crew failed to prepare the flight according to published procedures, did not follow the pre-departure checklist and failed to verify the position of the pressurization mode selector prior to take off. At an altitude of 33,000 feet, after suffering hypoxia, both pilot lost consciousness and situational awareness. Maybe one of them fell and the control column, causing the aircraft to enter an uncontrolled descent.
Final Report:

Crash of a Casa 212 Aviocar 20 in Ambon: 3 killed

Date & Time: Jul 9, 1997 at 1157 LT
Type of aircraft:
Operator:
Registration:
PK-NCS
Flight Type:
Survivors:
No
Schedule:
Langgur - Ambon
MSN:
201/41N
YOM:
1981
Flight number:
MZ7979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The departure from Langgur was delayed for few hours due to technical problems with the right engine, so it was decided to ferry the airplane to Ambon for repairs. On final approach to Ambon-Pattimura Airport in light rain and mist, the aircraft stalled and crashed 270 metres short of runway. The aircraft was destroyed and all three crew members were killed.
Probable cause:
Failure of the right engine on final approach for unknown reasons.

Crash of a Cessna 414A Chancellor in Zurich: 1 killed

Date & Time: Apr 10, 1997 at 2101 LT
Type of aircraft:
Operator:
Registration:
HB-LPN
Flight Type:
Survivors:
Yes
Site:
Schedule:
Colmar – Basel – Zurich
MSN:
414A-0842
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1006
Captain / Total hours on type:
350.00
Copilot / Total flying hours:
251
Copilot / Total hours on type:
2
Aircraft flight hours:
2318
Circumstances:
The crew was completing a flight from Colmar to Zurich with an intermediate stop in Basel. While on a night approach to runway 28 at Zurich-Kloten Airport, both engines lost power simultaneously. The aircraft lost height, struck a three-floor building and crashed on a second one located few dozen metres further. The captain was seriously injured while the copilot was killed.
Probable cause:
The accident was the consequence of the following factors:
- Insufficient flight preparation;
- Insufficient fuel supply;
- An emergency landing at night in a densely populated area following a double engine failure as a result of an inappropriate operation of the fuel selector switch.
Final Report:

Crash of a Beechcraft B90 King Air in Longmont

Date & Time: Jan 23, 1997 at 2050 LT
Type of aircraft:
Operator:
Registration:
N76GM
Flight Type:
Survivors:
Yes
Schedule:
Louisberg – Louisville – Vandalia – Longmont
MSN:
LJ-498
YOM:
1970
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1310
Captain / Total hours on type:
42.00
Aircraft flight hours:
10530
Circumstances:
The pilot had made a refueling stop at Vandalia, Illinois. She did not observe the refueling process, but the FBO also operated a King Air and she felt he knew the proper procedure to follow. The airplane was reportedly serviced with 235 gallons of Jet-A fuel (total capacity is 384 gallons). The pilot flew between 7,500 and 10,500 feet. When the airplane was 45 minutes from its destination, the fuel transfer pump lights illuminated, indicating the wing tanks were empty. The nacelle tank gauges registered 3/4 full and the pilot determined she had sufficient fuel to complete the flight. When the airplane was three minutes from its destination, both engines flamed out and the pilot made a wheels up forced landing. When the salvage company recovered the airplane, they reported finding no evidence of fuel aboard. The pilot was provided and used performance charts for the Beech 65-A90 instead of the Beech B90.
Probable cause:
Failure of the pilot to refuel the airplane, resulting in fuel exhaustion. Factors were the pilot's reference to similar but different aircraft performance charts, and the operator's failure to provide the pilot with the proper performance charts.
Final Report: