Crash of a Mitsubishi MU-2B-60 Marquise in Fort Pierce: 1 killed

Date & Time: Jun 25, 2006 at 1224 LT
Type of aircraft:
Operator:
Registration:
N316PR
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Fort Pierce - Murfreesboro
MSN:
761
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11000
Captain / Total hours on type:
2000.00
Aircraft flight hours:
4073
Circumstances:
Witnesses stated that they observed the twin-engine airplane roll into a steep right bank and enter a spin at a low altitude (less than 700 feet) during the initial climb. The airplane then descended and impacted terrain about 1.5 miles from the end of the departure runway. Some witnesses reported hearing an unusual engine noise just before the airplane began to roll and spin. Day visual meteorological conditions prevailed. Examination of the right engine revealed that the ring gear support of the engine/propeller gearbox had fractured in flight due to high cycle fatigue originating from the corner radii of the high-speed pinion cutout. The reason for the fatigue could not be determined. The ring gear support disengaged from the ring gear due to this failure, resulting in a disconnection in power being transferred from the engine power section to the propeller. In addition to the ability for a pilot to manually feather the propellers, and an automatic feathering feature, the engine (Honeywell TPE-331) design also includes a “Negative Torque Sensing” (NTS) system that would automatically respond to a typical failed engine condition involving a propeller that is driving the coupled engine. Feathering the propeller reduces drag and asymmetric yawing due to the failed engine. All Federal Aviation Administration (FAA) certification evaluations for one-engine inoperative handling qualities for the airplane type were conducted with the NTS system operational. According to the airplane manufacturer, the NTS system was designed to automatically reduce the drag on the affected engine to provide a margin of safety until the pilot is able to shut down the engine with the condition lever. However, if a drive train disconnect occurs at the ring gear support, the NTS system is inoperable, and the propeller can come out of feather on its own, if the disconnect is followed by a pilot action to retard the power lever on the affected engine. In this scenario, once the fuel flow setting is reduced below the point required to run the power section at 100% (takeoff) rpm, the propeller governor would sense an “underspeed” condition and would attempt to increase engine rpm by unloading the propeller, subsequently driving the propeller out of feather toward the low pitch stop. This flat pitch condition would cause an increase in aerodynamic drag on one side of the airplane, and unanticipated airplane control difficulty could result due to the asymmetry.
Probable cause:
The pilot’s loss of aircraft control during the initial climb which was precipitated by the sudden loss of thrust and increase in drag from the right engine, and the pilot’s failure to adhere to the published emergency procedures regarding the position of the failed engine power lever. Contributing to the accident was the fatigue failure of the right engine’s ring gear support for undetermined reasons, which rendered the propeller’s automatic drag reducing system inoperative.
Final Report:

Crash of a Beechcraft 350 Super King Air in Freiburg im Brisgau: 2 killed

Date & Time: Jan 12, 2006 at 1826 LT
Operator:
Registration:
D-CUNO
Flight Type:
Survivors:
No
Schedule:
Karlsruhe – Freiburg im Breisgau
MSN:
FL-311
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
1500
Circumstances:
After the crew dropped off passengers at Karlsruhe-Baden-Baden Airport, he was returning to his base in Freiburg im Breisgau. On final approach to runway 16 in marginal weather conditions (poor visibility due to night and fog), the crew descended too low when the aircraft collided with trees and crashed in a wooded area located 450 metres short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and both pilots were killed.
Probable cause:
The aircraft impacted ground during a controlled descent after the crew took the decision to continue the approach under VFR mode in poor visibility due to the night and foggy conditions.

Crash of a PZL-Mielec AN-28 in Zalingei: 2 killed

Date & Time: Dec 24, 2005
Type of aircraft:
Operator:
Registration:
ER-AJE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Zalingei - Al Fashir
MSN:
1AJ006-12
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Zalingei Airport, en route to Al Fashir on behalf of the African Union, the twin engine aircraft crashed in unknown circonstances. Both pilots, Ukrainian and Moldavian citizens, were killed.

Crash of a Fletcher FU-24-950 in Whangarei: 2 killed

Date & Time: Nov 22, 2005 at 1142 LT
Type of aircraft:
Operator:
Registration:
ZK-DZG
Flight Type:
Survivors:
No
MSN:
207
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
16000
Captain / Total hours on type:
2382.00
Aircraft flight hours:
10597
Circumstances:
On 21 November 2005, the day before the accident, the pilot had completed a day of aerial topdressing in ZK-DZG, a New Zealand Aerospace Industries Fletcher FU24-950, then flown the aircraft with his loader-driver as a passenger to Whangarei Aerodrome. That evening the pilot contacted his operator’s (the company’s) chief engineer in Hamilton and said that the airspeed indicator in ZK-DZG was stuck on 80 knots. The chief engineer told him the pitot-static line for the indicator was probably blocked and to have a local aircraft engineer blow out the line. Early the next morning, the day of the accident, the pilot flew ZK-DZG with his loader-driver on board to an airstrip 50 km north-west of Whangarei to spread fertiliser on a farm property. As the morning progressed, the weather conditions became unsuitable for aerial topdressing. At about 1020, the pilot used his mobile telephone to talk to another company pilot at Kerikeri, and told him that the wind was too strong for further work. The conversation included general work-related issues and ended about 1045, with the pilot saying that he was shortly going to return to Whangarei and go to his motel. Before leaving for Whangarei, the pilot spoke with a truck driver who had delivered fertiliser to the airstrip about 1100. The driver commented later that the pilot said the wind had picked up enough to preclude further topdressing. After they had covered the fertiliser, the pilot told the driver that he and the loader-driver would fly to Whangarei. The driver did not recall anything untoward, except that the pilot had casually mentioned there was some electrical fault causing an amber light in the cockpit to flicker and that it would only be a problem if a second light came on. He said the pilot did not appear to be concerned about the light. The driver then left and did not see the aircraft depart. The pilot used his mobile telephone to tell an aircraft engineer at Whangarei Aerodrome about the airspeed indicator problem and asked him if he could have a look at it and blow out the pitot-static system. The engineer believed the call was made from the ground at about 1130, but he could not be certain of the time. The engineer agreed to rectify the problem and the pilot said he would arrive at the Aerodrome about noon. The engineer said he did not know that the pilot had spent the previous night in Whangarei or that the aircraft had been parked at the Aerodrome overnight. ZK-DZG was equipped with a global positioning system (GPS) and its navigation data was downloaded for analysis. From the data it was established that the aircraft departed from the airstrip at 1131 and flew for about 39 km on a track slightly right of the direct track to Whangarei Aerodrome, before altering heading direct to the aerodrome and Pukenui Forest located 5 km west of Whangarei city. A witness who had some aeroplane pilot flying experience, and was on a property close to the track of ZK-DZG, said he saw the aircraft fly past shortly after about 1130 at an estimated height of 500 feet. He watched it fly in the direction of Pukenui Forest for about 40 seconds before turning his head away. A short time later he turned again to look at the aircraft, which by then was just above the horizon about 2 ridges away. He said there was a strong, constant wind blowing from the right (south) of the aircraft, which appeared to be drifting sideways and rocking its wings. He then saw the aircraft enter a steep descending turn that seemed to tighten before it disappeared from view. He estimated it to have turned about 270 degrees. Another witness near the aircraft track and accident site reported seeing the aircraft at about 1140 flying just above the tree line and thought it might have been “dusting” the forest. The aircraft then turned and disappeared behind some trees. Other witnesses who heard or saw the aircraft described the weather as squally throughout the morning with strong winds from the south, and said that near the time of the accident there was no rain. The witnesses noticed nothing untoward with the aircraft itself, and at the time none was concerned that the aircraft may have been involved in an accident. The local aircraft engineer said he was not concerned when ZK-DZG did not arrive at Whangarei, because from his experience it was not unusual for agricultural pilots to change their plans at the last minute and to not inform the engineers. He described his conversation with the pilot as being casual and said the pilot did not mention that he was finishing topdressing for the day because of the weather. He thought the pilot was just trying to fit in the maintenance work and that his plans had changed. The pilot had not asked him to provide any search and rescue watch, nor did the engineer expect him to because he could not recall any pilot having asked him to do so. There was no evidence that the pilot made any radio calls during the flight. The frequency to which the radio was selected and its serviceability could not be determined because of the accident damage. At about 2200 a member of the pilot’s family contacted the emergency services when she became concerned that there had been no contact from the pilot. An extensive aerial search began at first light the next morning, and at about 1120 the wreckage of ZK-DZG was located about 50 metres (m) below a ridge in a heavily wooded area of Pukenui Forest, at an elevation of 920 feet above sea level. Both occupants were fatally injured.
Probable cause:
Findings are listed in order of development and not in order of priority.
- The pilot was correctly licensed, experienced and authorised for the flight.
- The pilot was operating the aircraft in an unserviceable condition because of a stuck airspeed indicator, which prevented him accurately assessing the aircraft airspeed. Consequently the
aircraft could have exceeded its airspeed limitations by some degree in the turbulent conditions.
- The structural integrity of the vertical fin had been reduced to such an extent by a cluster of unnoticed pre-existing fatigue cracks in its leading edge that eventual failure was inevitable. When the fin failed, it brought about an unrecoverable loss of control and the accident.
- Although the early design of the vertical fin met recognised requirements, it did not provide for any structural redundancy and the leading edge of the fin (a structural component) was not
damage-tolerant.
- The cracks in the fin leading edge went unnoticed until the failure, most likely because an approved black rubber anti-abrasion strip along that surface had prevented any detailed examination of it.
- The approved maintenance programmes did not reflect the inspection-dependent nature of the vertical fin for its ongoing airworthiness, with the inspection periods having been extended over
the years without full consideration given to the importance of frequent inspections for timely detection of fatigue damage.
- There was no evidence that the fitment of a more powerful STC-approved turbine engine, in place of a piston engine, had initiated the fatigue cracks in the fin leading edge. However, once
started, the extra engine power might have contributed to the rate of propagation of the cracks.
- The vertical fin defects and failures in the Fletcher aircraft over the years were not confined to turbine-powered aircraft.
- The CAA’s STC approval process for the turbine engine installation was generally robust and had followed recognised procedures, but the process should have been enhanced by an in-depth
evaluation of the fatigue effects on the empennage.
- Given the generally harsh operating environment and frequency of operations for the turbine powered Fletcher, the continued airworthiness requirements of the fin were not scrutinised as
robustly as they should have been during the STC approval process. Consequently the maintenance programmes had not been improved to ensure the ongoing structural integrity of the fin.
Final Report:

Crash of a De Havilland DHC-2 Beaver near Elross Lake: 1 killed

Date & Time: Sep 1, 2005 at 1630 LT
Type of aircraft:
Operator:
Registration:
C-FODG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Pons Camp - Squaw Lake
MSN:
205
YOM:
1952
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2550
Captain / Total hours on type:
1700.00
Aircraft flight hours:
20900
Circumstances:
The float-equipped de Havilland DHC-2 Beaver (registration C-FODG, serial number 205) departed the outfitter base camp at Squaw Lake, Quebec, at 0925 eastern daylight time, with a passenger and a few supplies on board, for a round-trip visual flight rules (VFR) flight to two wilderness camps, Camp 2 and Camp Pons. The weather in Squaw Lake was suitable for visual flight at the time of take-off but was forecast to deteriorate later in the day. The pilot completed the flights to the two camps and on the way back to Squaw Lake, the weather forced the pilot to make a precautionary landing on Elross Lake, 15 nautical miles (nm) northwest of Squaw Lake. At 1630, he reported to the company via high frequency (HF) radio that he intended to take off from Elross Lake, as there seemed to be a break in the weather. Rescue efforts were initiated in the evening when the aircraft did not arrive at the base camp. The aircraft was located at 1230 the following day, 4 nm from Elross Lake. The aircraft was destroyed by a post-impact fire. The pilot sustained fatal injuries.
Probable cause:
Finding as to Causes and Contributing Factors:
1. The pilot attempted to cross the mountain ridge in adverse weather, and the aircraft stalled at an altitude from which recovery was not possible. Loss of visual references, strong updrafts, moderate to severe turbulence and possible wind shear likely contributed to the onset of the aerodynamic stall.
Other Finding:
1. Had this been a survivable accident, rescue efforts may have been compromised by a lack of communication. A satellite phone provides a more effective means of communication when in remote areas.
Final Report:

Crash of a Beechcraft 200 Super King Air in Squamish: 2 killed

Date & Time: Jul 28, 2005 at 0840 LT
Operator:
Registration:
C-FCGL
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Vancouver – Smithers
MSN:
BB-190
YOM:
1976
Flight number:
NT202
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2700
Captain / Total hours on type:
100.00
Copilot / Total flying hours:
1200
Copilot / Total hours on type:
80
Circumstances:
A Raytheon Beechcraft King Air 200 (registration C-FCGL, serial number BB190) operating as NTA202 (Northern Thunderbird Air), departed Vancouver, British Columbia, at 0824 Pacific daylight time on 28 July 2005 for a visual flight rules flight to Smithers, British Columbia, with a crew of two on board. The aircraft did not arrive at its destination, and a search was commenced later that same day. The aircraft was found on 30 July 2005. The crash site was in a narrow canyon at an elevation of about 3900 feet above sea level, in an area of steeply rising terrain. Both occupants were fatally injured. A post-crash fire destroyed most of the aircraft. The emergency locator transmitter was destroyed in the fire and no signal was detected. The crash occurred at about 0840 Pacific daylight time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The aircraft was flown up a narrow canyon into rapidly rising terrain for reasons that could not be determined. The aircraft’s proximity to terrain and the narrowness of the canyon precluded a turn, and the aircraft’s climb rate was insufficient to clear the rising terrain.
2. The pilot decision-making training received by the crew members was ineffective because they were unprepared for the unique hazards and special operating techniques associated with flying low in mountainous terrain.
Finding as to Risk:
1. The company operations manual (COM) gave no guidance to the crew for the operation of a visual flight rules (VFR) flight, except for the provision that it should not be conducted closer to obstacles than 500 feet vertically and horizontally.
Final Report:

Crash of a Swearingen SA226T Merlin IIIB in Teterboro

Date & Time: May 31, 2005 at 1130 LT
Registration:
N22DW
Flight Type:
Survivors:
Yes
Schedule:
Nantucket – Teterboro
MSN:
T-317
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2676
Captain / Total hours on type:
1400.00
Aircraft flight hours:
4698
Circumstances:
During takeoff from the departure airport, as the pilot advanced the throttles, the aircraft made a "sudden turn to the right." The pilot successfully aborted the takeoff, performed an engine run-up, and then took off without incident. The pilot experienced no anomalies during the second takeoff or the flight to the destination airport. As he reduced the power while in the traffic pattern, at the destination airport, the left engine accelerated to 60 percent power. The pilot reported to the tower that he had "one engine surging and another engine that seems like I lost control or speed." The pilot advanced and retarded the throttles and the engines responded appropriately, so he continued the approach. As the pilot flared the airplane for landing, the left engine surged to 65 percent power with the throttle lever in the "idle" position. The airplane immediately turned to the right; the right wing dropped and impacted the ground. Disassembly of the engines revealed no anomalies to account for surging, or for an uncommanded increase in power or lack of throttle response. Functional testing of the fuel control units and fuel pumps revealed the flight idle fuel flow rate was 237 and 312 pounds per hour (pph), for the left and right engines, respectively. These figures were higher than the new production specification of 214 pph. According to the manufacturer, flight idle fuel flow impacts thrust produced when the power levers are set to the flight idle position and differences in fuel flow can result in an asymmetrical thrust condition.
Probable cause:
The pilot's improper decision to depart with a known deficiency, which resulted in a loss of control during landing at the destination airport. A factor was the fuel control units' improper flight idle fuel flow rate.
Final Report:

Crash of a Beechcraft 350 Super King Air in El Junquito: 2 killed

Date & Time: May 24, 2005 at 1600 LT
Registration:
YV-783CP
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Caracas – Charallave
MSN:
FL-313
YOM:
2001
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was performing a ferry flight from Caracas-Maiquetía-Simón Bolívar Airport to Charallave. While cruising in poor weather conditions, the twin engine aircraft struck the slope of a mountain located near El Junquito, about 35 km northwest of Charallave-Óscar Machado Zuloaga Airport. The aircraft was destroyed and both pilots were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Piper PA-31-350 Navajo Chieftain off Pompano Beach

Date & Time: Oct 21, 2004 at 1748 LT
Operator:
Registration:
N61518
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Moss Town – Fort Lauderdale
MSN:
31-7552022
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Aircraft flight hours:
19269
Circumstances:
Before the start of the trip, the pilot was reportedly given $500.00 cash by the operator to purchase fuel. The pilot stated that the first leg of the flight from KFLL to MYEF departed with the main fuel tanks full and approximately 10 gallons in each of the auxiliary fuel tanks. There were no deviations en-route, and the uneventful flight lasted a reported 1 hour 40 minutes. After landing in Exuma International Airport, the main fuel tanks contained slightly more than 1/2 fuel capacity. Ten gallons of fuel were added to each of the two auxiliary fuel tanks at MYEF, no additional fuel was purchased. The flight departed for KFLL, and during the climb to 10,000 feet, he leaned the fuel/air mixture. During the cruise portion of the flight, the fuel in the auxiliary fuel tanks was consumed then he switched to the main fuel tanks to supply fuel to the engines. The flight crossed the DEKAL intersection at 4,000 feet, which is about 31 nautical miles southeast of KFLL, continued, and the right engine manifold pressure decreased, the cylinder head temperature reached red line indication, and the engine sputtered. He declared an emergency with air traffic control and the controller provided vectors to KFLL which he verbally acknowledged but did not comply with. While operating single engine, with the engine operating at full power, he reported no discrepancies with the left engine. He reported he could reach KFLL but was concerned about flying over a populated area at a low altitude, and was losing altitude. Contrary to the statement made by the pilot that he was not able to maintain altitude while flying single-engine, the airplane was capable of a rate of climb greater than 170 feet-per-minute if flown properly. He elected to ditch the airplane in the Atlantic Ocean; the airplane was not recovered. The operator was asked repeatedly by NTSB for historical fuel receipts and flight hours for N61518 but did not comply. NTSB review of fuel consumption calculations performed by the Federal Aviation Administration (FAA) Inspector-In-Charge revealed the aircraft would have experienced fuel exhaustion at the approximate location and time when the pilot declared an emergency with ATC following failure of the right engine. The NTSB did not receive the NTSB requested detailed, signed, dated statement from the pilot.
Probable cause:
The pilot's inadequate in-flight planning/decision, which resulted in fuel exhaustion and the loss of engine power in one engine. Contributing factors were the pilot's inadequate handling of the aircraft following failure of the right engine for his failure to extract maximum single engine performance, and his failure to properly refuel the aircraft.
Final Report:

Crash of a Canadair RegionalJet CRJ-200LR in Jefferson City: 2 killed

Date & Time: Oct 14, 2004 at 2215 LT
Operator:
Registration:
N8396A
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Little Rock – Minneapolis
MSN:
7396
YOM:
2000
Flight number:
NW3701
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6900
Captain / Total hours on type:
973.00
Copilot / Total flying hours:
761
Copilot / Total hours on type:
222
Aircraft flight hours:
10168
Aircraft flight cycles:
9613
Circumstances:
On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlines flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A, crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, Jefferson City, Missouri. The airplane was on a repositioning flight from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport, Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-induced aerodynamic stall and were unable to be restarted. The captain and the first officer were killed, and the airplane was destroyed. No one on the ground was injured.
Probable cause:
The National Transportation Safety Board determines that the probable causes of this accident were:
1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training;
2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and
3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition.
Contributing to this accident were:
1) the engine core lock condition, which prevented at least one engine from being restarted, and
2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating.
Final Report: