Crash of a Canadair RegionalJet CRJ-100SE in Moscow

Date & Time: Feb 13, 2007 at 1637 LT
Operator:
Registration:
N168CK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Moscow - Berlin
MSN:
7099
YOM:
1996
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9100
Copilot / Total flying hours:
2679
Copilot / Total hours on type:
68
Aircraft flight hours:
3814
Aircraft flight cycles:
1765
Circumstances:
The crew was completing a positioning flight from Moscow to Berlin for maintenance purposes. After the crew was cleared to start up the engines, the aircraft was towed to the deicing pad where the crew requested a two-step deicing procedure. The deicing was completed at 1618LT and the crew was cleared for takeoff at 1636LT. After a course of 1,500 metres on runway 06 in snow falls, the pilot-in-command started the rotation when the aircraft rolled left and right. The right wing struck the ground, the aircraft went out of control, got inverted and crashed in a snow covered area located 450 metres further and 35 metres to the right of the runway. All three crew members escaped with minor injuries while the aircraft was destroyed. At the time of the accident, weather conditions were as follow: wind from 130 at 10 knots, horizontal visibility 1,000 metres in snow falls, vertical visibility 300 feet, OAT -6° and dewpoint at -7°.
Probable cause:
Loss of control at liftoff due to a loss of lift caused by a stall consecutive to an excessive accumulation of ice/frost on the critical surfaces despite the aircraft had been deiced/anti-iced prior to takeoff. The following findings were identified:
- The aircraft was deiced in a two-step procedure - deicing with Type I then anti-icing with Type IV. The treatment was completed at 1618LT, 19 minutes prior to the accident,
- At the time of the accident, there were moderate to strong snow falls at the airport,
- The crew did not receive the full meteorological bulletin prior to departure and failed to determine the correct holdover time,
- Referring to the actual weather conditions, the crew failed to proceed with a second deicing/anti-icing procedure,
- Lack of adequate check by crew members and/or the airline representatives regarding the quality of the anti-icing treatment,
- The crew failed to comply with AFM relating to the actual weather conditions,
- The takeoff was started at a speed that was 12 knots below the reference speed, increasing the stall condition with leading edges that were slightly contaminated with frost/ice.
Final Report:

Crash of a Cessna 525 CJ1 in Van Nuys: 2 killed

Date & Time: Jan 12, 2007 at 1107 LT
Type of aircraft:
Operator:
Registration:
N77215
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Van Nuys - Long Beach
MSN:
525-0149
YOM:
1996
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
38000
Captain / Total hours on type:
800.00
Aircraft flight hours:
3001
Circumstances:
Line personnel reported that as the airplane was being fueled, the second pilot loaded more than one bag in the left front baggage compartment. With fueling complete, line personnel saw the second pilot pull the front left baggage door down, but not lock or latch it. Witnesses near midfield of the 8,001-foot long runway, reported that the airplane was airborne, and the front left baggage door was closed. Witnesses near the end of the runway, reported that the airplane was about 200 feet above ground level (agl) and they noted that the front left baggage door was open and standing straight up. All of the witnesses reported that the airplane turned slightly left, leveled off, and was slow. The airplane began to descend, and the wings were slightly rocking before it stalled, broke right, and collided with the terrain. Investigators found no anomalies with the airframe or engines that would have precluded normal operation. The forward baggage doors' design incorporates a key lock in the lower center of each door, and two latches in the left and right bottom section of the doors. There are two hinges in the upper left and right sections of the door. The handles latched the door to the door frame in the fuselage. The key would be in the horizontal position in an unlocked condition, and in the vertical position in a locked condition. The front left baggage door was found within the main wreckage debris field and had sustained mechanical and thermal damage. The key lock was in the horizontal position. Several instances of a baggage door opening in flight have been recorded in Cessna Citation airplanes. In some cases, the door separated, and in others it remained attached. The crews of these other airplanes returned to the airport and landed successfully.
Probable cause:
The pilot's failure to maintain an adequate airspeed during the initial climb resulting in an inadvertent stall/spin. Contributing to the accident were the second pilots inadequate preflight, failure to properly secure the front baggage door, and the front left baggage door opening in flight, which likely distracted the first pilot.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander off Tauranga

Date & Time: Dec 28, 2006 at 1000 LT
Type of aircraft:
Operator:
Registration:
ZK-WNZ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tauranga - Hamilton
MSN:
278
YOM:
1971
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was ferrying the aircraft from Tauranga to a Hamilton maintenance facility when one of the engines failed. The pilot elected to turn back to Tauranga but, shortly after, the remaining engine failed. The pilot carried out a forced landing into a tidal estuary. The aircraft incurred substantial damage to the nose landing gear. Subsequent CAA safety investigation determined that on an earlier flight, the aircraft's electrical system incurred a defect that rendered several electrical components unserviceable, including the two tip/main fuel tank selector valves. No engineering inspection or rectification ensued and the operator ferried the aircraft from Great Barrier Island unaware that the engines were being fed from the tip tanks only. The operator departed Tauranga for Hamilton under similar circumstances, reaching the vicinity of the Kaimai Ranges when the tip tanks became empty.
Probable cause:
Fuel exhaustion.

Crash of a Swearingen SA227AC Metro III in Buenos Aires

Date & Time: Dec 15, 2006 at 1820 LT
Type of aircraft:
Operator:
Registration:
LV-WRA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Buenos Aires - Buenos Aires
MSN:
AC-429
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2666
Captain / Total hours on type:
1556.00
Copilot / Total flying hours:
1465
Copilot / Total hours on type:
1232
Aircraft flight hours:
34587
Circumstances:
The crew was performing a positioning flight from Buenos Aires-Ezeiza-Ministro Pistarini Airport to Buenos Aires-Aeroparque-Jorge Newbury Airport. Before departure, the captain switched off the Stall Alarm System for unknown reasons. Shortly after takeoff from runway 17, the climb gradient was small and landing gear were retracted at a very low altitude. The left wing stalled and struck the runway surface. Out of control, the aircraft impacted ground, slid for few dozen metres, overran the runway and came to rest in a field. Both pilots were uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control shortly after rotation due to the premature retraction of the landing gear and a takeoff completed with a low climb gradient in the second segment.
Final Report:

Crash of a Yakovlev Yak-40 in Caticlan

Date & Time: Nov 2, 2006 at 0745 LT
Type of aircraft:
Operator:
Registration:
RP-C2695
Flight Type:
Survivors:
Yes
Schedule:
Manila - Caticlan
MSN:
9 52 20 41
YOM:
1975
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew departed Manila-Ninoy Aquino Airport on a positioning flight to Caticlan to carry a group of tourists. After touchdown, the left tyre burst. The aircraft deviated to the left then veered off runway and contacted a grassy area. The left main gear collapsed and the aircraft came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after a tyre burst on landing.

Crash of a Gippsland GA8 Airvan in Monteverde National Park: 1 killed

Date & Time: Nov 2, 2006 at 0530 LT
Type of aircraft:
Operator:
Registration:
TI-BAH
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
San José – Liberia
MSN:
GA8-04-069
YOM:
2004
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot, sole on board, departed San José-Alajuela-Juan Santamaria Airport at 0500LT on a positioning flight to Liberia-Daniel Oduber Quiros Airport located in the Guanacaste cordillera. About 30 minutes into the flight, the single engine aircraft crashed in unknown circumstances in the Monteverde National Park. The aircraft was destroyed and the pilot was killed.

Crash of a Mitsubishi MU-2B-35 Marquise in Argyle: 1 killed

Date & Time: Sep 1, 2006 at 1115 LT
Type of aircraft:
Registration:
N6569L
Flight Type:
Survivors:
No
Schedule:
Tulsa - Argyle
MSN:
645
YOM:
1974
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
30780
Captain / Total hours on type:
10000.00
Aircraft flight hours:
6642
Circumstances:
Prior to the accident flight, the pilot obtained a preflight weather briefing and filed an instrument flight rules flight plan. The briefer noted no adverse weather conditions along the route. The airplane departed the airport at 0853, and climbed to FL190. The first two hours of the flight was uneventful, and the aircraft was handed off to Jacksonville Air Route Traffic Control Center (ZJX ARTCC) at 1053. The pilot contacted ZJX Crestview sector at 1054:45 with the airplane level at FL190. At 1102, the Crestview controller broadcasted an alert for Significant Meteorological Information (SIGMET) 32E, which pertained to thunderstorms in portions of Florida southwest of the pilot's route. At 1103, the controller cleared to the airplane to descend to 11,000 feet and the pilot again acknowledged. At 1110:21, the pilot was instructed to contact Tyndall Approach. The pilot checked in with the Tyndall RAPCON North Approach controller at 1110:39. The pilot was told to expect a visual approach. Shortly thereafter, the pilot transmitted, "...we're at 11,000, like to get down lower so we can get underneath this stuff." The controller told the pilot to stand by and expect lower [altitude] in 3 miles. About 15 seconds later, the controller cleared to pilot to descend to 6,000 feet, and the pilot acknowledged. At 1112:27, the pilot was instructed to contact Tyndall Approach on another frequency. The airplane's position at that time was just northwest of REBBA intersection. The Panama sector controller cleared the pilot to descend to 3,000 feet at his discretion, and the pilot acknowledged. There was no further contact with the airplane. The controller attempted to advise the pilot that radar contact was lost, but repeated attempts to establish communications and locate the airplane were unsuccessful. A witness, located approximately 1 mile south of the accident site, reported he heard a "loud bang," looked up and observed the airplane in a nose down spiral. The witness reported there were parts separating from the airplane during the descent. The witness stated it was raining and there was lightning and thunder in the area. Local authorities reported that the weather "was raining real good with lightning and the thunderstorm materialized very quickly." The main wreckage came to rest near the edge of a swamp in tree covered and high grassy terrain. The left wing, left engine, and the left wing tip tank were located in a wooded area approximately 0.6 miles northwest of the main wreckage. The left wing separated from the airplane inboard of the left engine and nacelle. Examination of the fracture surfaces indicated that both the front and rear spars failed from "catastrophic static up-bending overstress..." The airplane flew through an intense to extreme weather radar echo containing a thunderstorm. Although the controllers denied that there was any weather displayed ahead of the airplane, recorded radar and display data indicated that moderate to extreme precipitation was depicted on and near the route of flight. During the flight, the pilot was given no real-time information on the weather ahead. The airplane was equipped with a weather radar system and the system provided continuous en route weather information relative to cloud formation, rainfall rate, thunderstorms, icing conditions, and storm detection up to a distance of 240 miles. No anomalies were noted with the airframe and engines.
Probable cause:
The pilot's inadvertent flight into thunderstorm activity that resulted in the loss of control, design limits of the airplane being exceeded and subsequent in-flight breakup. A contributing factor was the failure of air traffic control to use available radar information to warn the pilot he was about to encounter moderate, heavy, and extreme precipitation along his route of flight.
Final Report:

Crash of a Douglas DC-3C off Charlotte Amalie

Date & Time: Jul 19, 2006 at 0720 LT
Type of aircraft:
Operator:
Registration:
N782T
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Charlotte Amalie - San Juan
MSN:
4382
YOM:
1942
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15750
Copilot / Total flying hours:
305
Aircraft flight hours:
32278
Circumstances:
The captain stated that the accident flight was a return flight to San Juan, Puerto Rico, after delivering U.S. Mail. The airplane was empty of cargo at the time of the accident. The first officer was flying the airplane. The takeoff roll and rotation at 84 knots was uneventful until about 100 feet above the ground when the gear was called out to be retracted. At that time, the left engine's rpm dropped from 2,700 to 1,000. He communicated to the first officer that he would be assuming control of the airplane. He then proceeded with verifying that the left engine had failed. Once confirmed, he proceeded with the failed engine check list and feathering the propeller. They advised air traffic control (ATC) of the situation and informed them that they were returning to land. The airplane would not maintain altitude and the airspeed dropped to about 75 knots. The captain stated that he knew the airplane would not make it back to the airport. Instructions were given to the two passengers to don their life vests and prepared for a ditching. The captain elected to perform a controlled flight into the water. All onboard managed to exit the airplane through the cockpit overhead escape hatch onto the life raft as the airplane remained afloat. About ten minutes later the airplane sank nose first straight down. The airplane came to rest at the bottom of the ocean, in about 100 feet of water. The airplane was not recovered. Underwater photos provided by the operator showed the nose and cockpit area caved in, the left engine's propeller was in the feathered position, and the right engine's propeller was in a low pitch position.
Probable cause:
The airplane's inability to maintain altitude for undetermined reasons, following a loss of power from the left engine.
Final Report:

Crash of a Dornier DO328Jet in Manassas

Date & Time: Jun 3, 2006 at 0719 LT
Type of aircraft:
Operator:
Registration:
N328PD
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Manassas - Myrtle Beach
MSN:
3105
YOM:
2000
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15615
Captain / Total hours on type:
2523.00
Copilot / Total flying hours:
819
Copilot / Total hours on type:
141
Aircraft flight hours:
2830
Circumstances:
Prior to departure on the maintenance repositioning flight, the captain discussed with the first officer an uneven fuel balance that they could "fix" once airborne, and a 25,000 feet msl restriction because of an inoperative air conditioning/pressurization pack. The captain also commented about the right pack "misbehaving", and a bleed valve failure warning. The captain also commented about aborting below 80 knots for everything, except for the bleed shutoff valve. During the takeoff roll, a single chime was heard, and the first officer reported a bleed valve fail message. The captain responded, "ignore it." Another chime was heard, and the first officer reported "lateral mode fail, pusher fail." The captain asked about airspeed and was advised of an "indicated airspeed miscompare." The captain initiated the aborted takeoff approximately 13 seconds after the second chime was heard. The crew was unable to stop the airplane, and it went off the end of the runway, and impacted obstructions and terrain. According to the flight data recorder, peak groundspeed was 152 knots and the time the aborted takeoff was initiated, and indicated airspeed was 78.5 knots. The captain and the airplane owner's director of maintenance were aware of several mechanical discrepancies prior to the flight, and the captain had advised the first officer that the flight was for "routine maintenance," but that the airplane was airworthy. Prior to the flight the first officer found "reddish clay" in one of the pitot tubes and removed it. A mechanic and the captain examined the pitot tube, and determined the tube was not obstructed. The captain's pitot tube was later found to be partially blocked with an insect nest. A postaccident examination of the airplane and aircraft maintenance log revealed that no discrepancies were entered in the log, and no placards or "inoperative" decals were affixed in the cockpit.
Probable cause:
The partially blocked pitot system, which resulted in an inaccurate airspeed indicator display, and an overrun during an aborted takeoff. A factor associated with the accident was the pilot-in-command's delayed decision to abort the takeoff.
Final Report:

Crash of a Cessna T207A Turbo Stationair 7 II in Pemberton: 1 killed

Date & Time: May 18, 2006 at 1506 LT
Operator:
Registration:
C-GGQR
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Pemberton – Edmonton
MSN:
207-0499
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1500
Circumstances:
The aircraft departed from Pemberton Airport, British Columbia, at about 1500 Pacific daylight time on a visual flight rules flight to Edmonton, Alberta. The aircraft initially climbed out to the east and subsequently turned northeast to follow a mountain pass route. The pilot was alone on this aircraft repositioning flight. The pilot had been conducting air quality surveys for Environment Canada’s Air Quality Research Section in the Pemberton area. The aircraft was operating on a flight permit and was highly modified to accept various types of probes in equipment pods suspended under the wings, a camera hatch type provision in the centre belly area, and carried internal electronic equipment. About 30 minutes after the aircraft took off, the Coastal Fire Service responded to a spot fire and discovered the aircraft wreckage in the fire zone. A post-crash fire consumed most of the airframe, and the pilot was fatally injured. The accident occurred at about 1506 Pacific daylight time.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot entered the valley at an altitude above ground that did not provide sufficient terrain clearance given the aircraft’s performance.
2. The pilot encountered steeply rising terrain, where false horizon and relative scale illusions in the climb are likely. Realizing that the aircraft would not likely be able to out-climb the approaching terrain, he turned to reverse his course.
3. The aircraft’s configuration, relatively high weight, combined with the effects of increased drag from the equipment, density altitude, down-flowing winds, and manoeuvring resulted in the aircraft colliding with terrain during the turn.
Findings as to Risk:
1. A detailed flight plan was not filed and special equipment, such as laser radiation emitting devices and/or hazardous substances were not reported. The absence of flight plan information regarding these devices could delay search and rescue efforts and expose first responders to unknown risks.
2. Transport Canada (TC) does not issue a rating/endorsement for mountain flying training. There are no standards established to ascertain the proficiency of a pilot in this environment. Pilots who complete a mountain flying course may not acquire the required skill sets.
3. There was no emergency locator transmitter (ELT) signal received. The ELT was destroyed in the impact and subsequent fire. Present standards do not require that ELTs resist crash damage.
4. “Flight permits – specific purpose” are issued for aircraft that do not perform as per the original type design but are deemed capable of safe flight. Placards are not required; therefore, pilots and observers approved to board may be unaware of the limitations of the aircraft and the associated risks.
5. The TC approval process allowed the continued operation of this modified aircraft for sustained environmental research missions under a flight permit authority. This circumvented the requirement to meet the latest airworthiness standards and removed the risk mitigation built into the approval process for a modification to a type design.
Other Findings:
1. The fuel system obstruction found during disassembly was a result of the post-crash fire.
2. The aircraft was operated at an increased weight allowance proposed by the design approval representative (DAR). Such operation was to be approved only in accordance with a suitably worded flight permit and instructions contained in the proposed document CN-MSC-011; however, this increased weight allowance was not incorporated to any flight authority issued by TC.
Final Report: