Crash of an Embraer EMB-820C Navajo in Monsenhor Gil: 2 killed

Date & Time: Feb 23, 2004 at 1100 LT
Registration:
PT-EBU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Picos – Teresina
MSN:
820-005
YOM:
1975
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following several flights during the last days, the crew departed Picos on the last leg to Teresina. While descending to Teresina-Senador Petrônio Portella Airport, the crew informed ATC about the failure of the left engine and reduced his altitude to attempt an emergency landing. The aircraft struck a tree and crashed in an open field located about 800 metres from a road. The wreckage was found 51 km southeast of Teresina Airport. Both pilots were killed.
Probable cause:
Failure of the left engine due to fuel exhaustion. The following findings were identified:
- Poor flight preparation,
- Complacency, overconfidence,
- Contempt for published procedures and poor judgment,
- The copilot's licence and medical documents were expired.
Final Report:

Crash of a Rockwell Shrike Commander 500S near Hobart: 1 killed

Date & Time: Feb 19, 2004 at 1643 LT
Operator:
Registration:
VH-LST
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hobart – Devonport
MSN:
500-3111
YOM:
1971
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
371
Captain / Total hours on type:
40.00
Circumstances:
The aircraft commenced taxying at Hobart for a Visual Flight Rules (VFR) ferry flight to Devonport. The pilot, who was the sole occupant, reported a departure time of 1643 to air traffic control, with an intention to climb to 8,500 ft and to fly a track of 319 degrees magnetic. Due to following traffic, the pilot was required to report leaving specific altitudes. At 1646, the pilot reported leaving 4,500 ft, and was advised that air traffic services were terminated. The acknowledgement of that call was the last communication heard from the pilot. At about 1800, the operator’s staff at Devonport advised the Hobart base that the aircraft had not arrived. The operator advised AusSAR and the Hobart air traffic control tower, and organised company search aircraft from both Hobart and Devonport. The non-flying occupant of the Hobart search aircraft sighted the wreckage at about 1930. Shortly after, a search and rescue helicopter arrived at the accident site. The pilot of the aircraft was found fatally injured in the wreckage. The wreckage was located 58 km from Hobart airport on a bearing of 320 degrees magnetic. Based on predictions of aircraft performance and the distance of the accident site from Hobart, the estimated time of the accident was 1656. There were no eyewitnesses to the accident. Aircraft flight profile The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to be. As such, and given that the aircraft was operating outside of radar coverage, there was no recorded flight profile information available. The pilot was not required to report cruising at 8,500 ft and there was no evidence to confirm that the aircraft had reached that altitude. However, based on the normal climb and cruise performance, forecast winds and the radio broadcasts made by the pilot, the aircraft should have reached an altitude of 8,500 ft approximately 35 km from Hobart at about 1651, which was 5 minutes prior to the estimated time of the accident at 1656.
Probable cause:
The trajectory analysis provided the ATSB with a high degree of confidence with respect to the aircraft altitude and speed at the time of the in-flight breakup. The aircraft’s speed could have readily accelerated to Vne during a rapid descent from the nominated cruise altitude of 8,500 ft to the break-up altitude of around 3,150 ft. At such a speed, a relatively small control input force or gusts encountered in the longitudinal (pitch) axis of the aircraft could have resulted in the symmetrical downward wing overloading and failure that occurred. There is no compelling evidence to support any one reason for the departure of the aircraft from the cruise altitude into a high speed dive type situation. However, there are a number of factors that provide some weight to the possibility of a flight upset related to operation of the autopilot. These factors include:
• The lack of any reference in the operations manual to the installation of a Bendix FCS-810 autopilot in LST and the lack of information in the operations manual on the operation of the FCS-810 autopilot
• The pilot’s relative inexperience in the operation of the particular autopilot system fitted to LST
• The operating characteristics of the autopilot system fitted to LST
• The illegible nature of the Aircraft Flight Manual supplement pertaining to the limitations and operating procedures for the autopilot system fitted to LST
• The autopilot controller pitch command wheel being found at the accident site in the maximum nose-down position
• Both elevator trim tabs being found at the accident site at or close to the maximum nose-down trim position. However, it is not possible to discount other explanations for the departure from cruise flight, including a runaway pitch-trim condition, pilot incapacitation, the effects of mountain waves and/or severe turbulence, or a combination of any of the above. On the evidence available to the investigation, it was not possible to conclusively determine the circumstances that led to the aircraft descending at speed to the altitude at which the in-flight breakup occurred.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Kahului

Date & Time: Feb 18, 2004 at 1352 LT
Type of aircraft:
Registration:
C-GPTE
Flight Type:
Survivors:
Yes
Schedule:
Honolulu – Oakland – Brooks
MSN:
31-7712059
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7923
Circumstances:
The airplane collided with terrain 200 yards short of the runway during an emergency landing following a loss of engine power. The pilot was on an intermediate leg of a ferry trip. Approximately 300 miles from land, the fuel flow and boost pump lights illuminated. Then, the right engine failed. The pilot flew back to the nearest airport; however, approximately 200 yards from the runway, the airplane stalled and the right wing dropped and collided with the ground. The fuel system had been modified a few months prior to the accident to allow for a ferry fuel tank installation. Post accident examination of the airplane could not find a reason for the power loss.
Probable cause:
The pilot's failure to maintain an adequate airspeed while maneuvering for landing on one engine, which resulted in an inadvertent stall. The loss of power in one engine for undetermined reasons was a factor.
Final Report:

Crash of a PZL-Mielec AN-2TP in Urimán: 1 killed

Date & Time: Oct 11, 2003 at 1600 LT
Type of aircraft:
Operator:
Registration:
YV-1128C
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
1G238-12
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Shortly after takeoff from Urimán Airport, while in initial climb, the single engine aircraft stalled and crashed in the Caroni River. The captain was killed and the copilot was injured. The aircraft was destroyed. Possible engine failure.

Crash of a Fletcher FU-24-950M near Matawai

Date & Time: Sep 20, 2003 at 1015 LT
Type of aircraft:
Operator:
Registration:
ZK-BDS
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Motu - Opotiki
MSN:
001
YOM:
1954
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed during bad weather. Andrew Wilde was flying and George Muir was a passenger. While enroute from Motu - Opotiki the gully became un-negotiable, so Andrew decided to return to Motu by flying a reciprocal course low level, depicted by arrows on his hand held marine GPS. During the return trip to Motahora up the Otara river valley, he found that the cloud base had lowered even further than when he entered the valley 6 minutes prior & he became fully reliant on that little GPS. The GPS became our enemy & lured Andrew into the cloud base, which ended our flight abruptly.
Testimony from George Muir, loader driver and passenger during this flight.

Crash of a Rockwell Grand Commander 690 in Soto la Marina: 1 killed

Date & Time: Sep 16, 2003 at 1430 LT
Registration:
N302WB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Soto La Marina - Laredo
MSN:
690-11003
YOM:
1971
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
On September 16, 2003, at 1430 central daylight time, an Aero Commander 690 twin-engine airplane, N302WB was destroyed upon impact with trees and terrain while attempting a takeoff from an airstrip near Soto La Marina, in the State of Tamaulipas, in the Republic of Mexico. The commercial pilot, sole occupant of the airplane, was fatally injured. The airplane was registered to the QEAT-4 LLC., in Naples, Florida, and was being operated by the MGS Corporation of Laredo, Texas. Visual meteorological conditions prevailed for the business flight for which no flight plan was filed. The flight's destination was reported to be Laredo, Texas. Local authorities reported that the turboprop powered airplane, serial number 11003, had previously sustained some damage to the nose landing gear and the owner had replaced the nose landing gear prior to attempting to depart from the airstrip.

Crash of a Cessna 551 Citation II/SP in Sorocaba: 1 killed

Date & Time: Jul 23, 2003 at 0840 LT
Type of aircraft:
Operator:
Registration:
PT-LME
Flight Type:
Survivors:
Yes
Schedule:
Lins - Sorocaba
MSN:
551-0023
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3920
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
90
Aircraft flight hours:
8761
Circumstances:
The aircraft departed Lins Airport on a ferry flight to Sorocaba with two pilots on one passenger (the owner) on board. The aircraft was transferred to Sorocaba Airport for maintenance purposes. While descending, the crew was informed that runway 36 was in use and that three small aircraft were completing local training in the circuit. In good weather conditions, the captain decided to complete a straight-in approach to runway 18. After touchdown, the aircraft was unable to stop within the remaining distance. It overran, crossed a road and came to rest into a ravine. The passenger escaped uninjured, the copilot was seriously injured and the captain was killed. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the crew who completed an unstabilized approach and landed too far down the runway (about a half way down) at an excessive speed. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were identified:
- The crew did not make any approach briefing,
- The crew failed to follow the approach checklist,
- The aircraft had deficiencies in maintenance, particularly with regard to the brakes systems,
- The techlogs were out of date,
- Maintenance was periodic but insufficient,
- Although the runway 36 was in use, the captain preferred to land on runway 18,
- The aircraft was unstable on short final and landed too far down the runway, reducing the landing distance available,
- The aircraft' speed upon landing was excessive, preventing the reverse thrust systems to be activated,
- The captain took over control and activated the reverse thrust system on the right engine only,
- Poor crew coordination,
- The crew was operating in a conflict environment after touchdown,
- Poor judgment of the situation,
- Poor flight planning,
- Lack of crew discipline.
Final Report:

Crash of a Cessna 208B Super Cargomaster in Lorain

Date & Time: May 15, 2003 at 1710 LT
Type of aircraft:
Operator:
Registration:
N208AD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lorain - Anderson
MSN:
208B-0063
YOM:
1987
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3500
Captain / Total hours on type:
1500.00
Aircraft flight hours:
12059
Circumstances:
The pilot departed in a Cessna 208B, and shortly after takeoff, he experienced a power loss. He set up for a forced landing and during the ground roll, the nose wheel sunk into the soft terrain and the airplane nosed over. Fuel was found in both wings; however, the fuel line between the fuel selector and the engine contained only trace amounts of fuel. One fuel selector was found in the OFF position, and the other fuel selector was mid-range between the OFF and ON positions. The airplane was equipped with an annunciator warning light and horn to warn if either fuel selector was turned off. The annunciator was popped out and did not make contact with the annunciator panel. The warning horn was checked and found to be inoperative, and the electrical circuitry leading to the horn was checked and found to be operative. The engine was test run with no problems noted. According to the Pilot's Operating Handbook, the position of the fuel selectors are to be checked three times before takeoff: including cabin preflight, before engine start, and before takeoff. The pilot reported that he departed with both fuel selectors on and had not touched them when the power loss occurred. A representative of Cessna Aircraft Company reported that there was sufficient fuel forward of the fuel selector valves to takeoff and fly for a few miles prior to experiencing fuel exhaustion.
Probable cause:
The pilot's failure to verify the position of the fuel selectors prior to takeoff, which resulted in a power loss due to fuel starvation. A factor was the failure of the fuel selector warning horn.
Final Report:

Crash of a Fletcher FU-24-101 in Douglas: 2 killed

Date & Time: Apr 4, 2003 at 1830 LT
Type of aircraft:
Operator:
Registration:
ZK-LTF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Stratford - Stratford
MSN:
200
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1438
Captain / Total hours on type:
340.00
Aircraft flight hours:
5332
Circumstances:
The pilot had arranged to topdress properties for three clients, one of whom had three separate blocks to be treated. He departed from Stratford Aerodrome at 0653 hours in ZK-LTF for the first airstrip, located some 7 km to the north-east. After an initial reconnaissance flight, he began topdressing at 0722, and finished this block at 1034 hours. Via brief landings at Stratford and another airstrip 11 km to the north, he positioned the aircraft to a strip near Huiroa. The remainder of the day’s work was carried out from this strip. Four blocks were treated from this location: the first was 8 km to the north-west of the strip, the second immediately to the north, the third some 3 km west and the last 4.5 km to the south, adjacent to the Strathmore Saddle. A reconnaissance of the fourth block was flown at 1518, but actual spreading on this property was not commenced until 1755 hours. Two loads of urea were spread on the fourth block between 1755 and 1812 hours, with a 12-minute pause until the final take-off at 1824. During this break, the last of the urea was loaded, the fertiliser bins secured and the loading vehicle parked. It is not known if the aircraft was refuelled at this time. The loader driver boarded the aircraft after completing his duties, the apparent intention being to accompany the pilot back to Stratford on completion of the last drop. On arrival over the property at 1825, the pilot performed one run towards the south, made a left reversal turn, spread another swath on a northerly heading, and pulled up to commence another reversal turn to the left. At some time after this pull-up, the aeroplane struck the ground heavily on a south-westerly heading, killing both occupants on impact. Later in the evening, the pilot’s wife reported the aircraft and its occupants overdue, and a ground search was commenced, initially by friends and associates. The wreckage and the bodies of the crew were found about half an hour after midnight. The accident occurred during evening civil twilight, at approximately 1830 hours NZST, adjacent to the Strathmore Saddle, at an elevation of about 530 feet.
Probable cause:
Conclusions:
- The pilot was licensed, rated and fit for the flights being undertaken.
- The aeroplane had a current Airworthiness Certificate and had been maintained in accordance with current requirements.
- No pre-accident aircraft defect was found.
- The impact was consistent with partial recovery from a dive with insufficient height to do so.
- No conclusive reason could be found for the aircraft to have been in such a situation.
- Light conditions were probably conducive to difficult height judgement.
- The pilot’s judgement may have further been eroded by fatigue and a degree of carbon monoxide absorption.
- The accident was not survivable.
Final Report:

Crash of a Rockwell Grand Commander 690B in Homerville: 2 killed

Date & Time: Mar 27, 2003 at 0113 LT
Operator:
Registration:
N53LG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mount Pleasant – Titusville
MSN:
690-11523
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3581
Captain / Total hours on type:
47.00
Aircraft flight hours:
6317
Circumstances:
The flight was in cruise flight at 27,000 feet when the airplane encountered unforecasted severe turbulence. The pilot made a "mayday" on the airplane radio to Jacksonville Center. Within several seconds the airplane accelerated from 175 knots through 300 knots ground speed and descended from 27,000 feet to 16,500 feet. The airplane disappeared from radar coverage and was located by Sheriff Department personnel 15 miles north of Homerville, Georgia, in a swampy area. Airframe components recovered from the accident site were submitted to the NTSB Materials laboratory for examination. The examinations revealed all failures were due to overload. Examination of the airframe revealed that the airframe design limits were exceeded. The pilot did not obtain a weather briefing before the flight departed.
Probable cause:
An in-flight encounter with unforecasted severe turbulence in cruise flight resulting in the design limits of the airplane being exceeded due to an overload failure of the airframe, and collision with a swampy area.
Final Report: