Crash of a Piper PA-31-350 Navajo Chieftain in Kenai: 6 killed

Date & Time: Dec 23, 1987 at 0611 LT
Operator:
Registration:
N496SC
Flight Phase:
Survivors:
Yes
Schedule:
Kenai - Anchorage
MSN:
31-7752077
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
14500
Circumstances:
The pilot had just departed the runway when he reported to the flight service station that he had engine problems. The aircraft was observed by witnesses to be about 300 feet on a descending downwind. The pilot stated that he was circling for runway 01. Surviving passengers described the engines as running rough and uneven. The investigation revealed that the aircraft's weight was more than the pilot had calculated and the CofG was 3.4 inches further aft than was calculated. However, the weight and CofG were within limits. Examination of the engine disclosed that the right engine had an extensive cylinder head crack, a partially disconnected intake pipe, and was capable of producing 55% of rated power. The left engine had seven severely worn cam lobes. The rudder trim was deflected full left at impact. The evidence indicated that the pilot had retarded the throttle for the left engine and was using only the right engine to sustain flight. Exam of company checklist usage revealed several different improper versions. The pilot and five passengers were killed. Two others passengers and two people on the ground were injured.
Probable cause:
Occurrence #1: loss of engine power (partial) - mech failure/malf
Phase of operation: takeoff - initial climb
Findings
1. 1 engine - failure, partial
2. (c) engine assembly, cylinder - failure,total
3. (c) engine assembly, cylinder - fatigue
4. (f) induction air control, intake manifold - separation
----------
Occurrence #2: loss of engine power
Phase of operation: maneuvering
Findings
5. (f) 1 engine - failure, partial
6. (f) engine assembly, camshaft - worn
7. (f) maintenance, 100-hour inspection - inadequate - company maintenance personnel
8. (c) emergency procedure - improper - pilot in command
9. (c) throttle/power control - improper use of - pilot in command
----------
Occurrence #3: forced landing
Phase of operation: descent - emergency
----------
Occurrence #4: in flight collision with terrain/water
Phase of operation: descent - emergency
Findings
10. (f) trim setting - improper - pilot in command
11. Lowering of flaps - performed
12. Object - tree(s)
13. Object - residence
Final Report:

Crash of a Cessna 402C in Chadron: 2 killed

Date & Time: Dec 22, 1987 at 2057 LT
Type of aircraft:
Operator:
Registration:
N105GP
Survivors:
Yes
Schedule:
Alliance - Chadron
MSN:
402C-0642
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6865
Captain / Total hours on type:
169.00
Aircraft flight hours:
8229
Circumstances:
The aircraft was on a flight to Chadron via Chadron VOR. About 30 miles south-southeast of the VOR, the pilot requested and was cleared to fly direct to Ackme IAF for an NDB runway 02 approach. The aircraft continued toward the VOR which was in the same general direction, but 11.9 miles south of Ackme. The NDB was at the airport. Ackme IAF was 9 miles southwest of the airport on a bearing of 227° and defined by an intersection with the 356° radial of the VOR. About 3 to 4 miles southeast of the VOR, radar service was transmitted and frequency change was made. Subsequently, the aircraft struck trees on a ridge and crashed. Initial impact occurred in wings level flight at approximately 4,480 feet on a direct route between the VOR and Ackme IAF. An investigation revealed that after the frequency change, the aircraft continued to the VOR, then maneuvered as if the pilot was flying the NDB approach, but was using the VOR as the IAF. Radar data showed contact was lost after a procedure turn was made and the aircraft was outbound about 6 miles northeast of the VOR. The crash site, however, was about 3 miles west-southwest of where radar contact was last recorded. The weather at Chadron was in part: 500 feet overcast, 1.5 mile visibility with light snow and fog. No preimpact part failure/malfunction was found. The passenger was seriously injured and both pilots were killed.
Probable cause:
Occurrence #1: in flight collision with object
Phase of operation: approach
Findings
1. (f) light condition - dark night
2. (f) weather condition - low ceiling
3. (f) weather condition - fog
4. (f) weather condition - snow
5. (c) ifr procedure - improper - pilot in command
6. Planned approach - discontinued
7. (c) proper altitude - not maintained - pilot in command
8. (f) terrain condition - high terrain
9. (f) object - tree(s)
Final Report:

Crash of an Embraer EMB-120RT Brasília in Bordeaux: 16 killed

Date & Time: Dec 21, 1987 at 1510 LT
Type of aircraft:
Operator:
Registration:
F-GEGH
Survivors:
No
Schedule:
Brussels - Bordeaux
MSN:
120-033
YOM:
1986
Flight number:
AF1919
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
16
Captain / Total flying hours:
2394
Captain / Total hours on type:
101.00
Copilot / Total flying hours:
1326
Copilot / Total hours on type:
215
Aircraft flight hours:
2505
Circumstances:
Following an uneventful flight from Brussels, the crew contacted Bordeaux Approach at 15:01 and was vectored for an ILS approach to runway 23. Visibility was poor with low clouds at 100 feet and a runway visual range (RVR) of between 650 and 350 metres. Flight 1919 crossed the KERAG beacon, the initial approach fix (IAF) at an altitude of FL144, at 15:04:40. Cloud base was still around 100 feet so the crew requested to enter a holding pattern to the south of the airport. The weather conditions slightly improved during the next few minutes and Bordeaux Approach reported a cloud base at 160 feet. Flight 1919 had not reached the holding pattern yet and the pilot decided to attempt to rejoin the ILS. At 15:06:38 the flight was cleared direct to the BD beacon and to descend down to 2000 feet. At the BD beacon, the flight was cleared for final approach and instructed to contact Bordeaux Tower. The airplane had overshot the centreline and was slightly right on the glidepath. Bordeaux Tower then instructed the flight to report over the Outer Marker, which was acknowledged by the captain. After crossing the Outer Marker, the airplane was still not properly established on the ILS. The airplane descended below the glideslope with the crew hurriedly deploying flaps and landing gear. The captain did not contact Bordeaux Tower as requested. Instead he took over control of the airplane, attempting to continue the approach. Both crew members had very little time to adapt to their new roles as the airplane was descending below the glide slope. The descent continued until the aircraft struck tree tops and crashed in the Eysines forrest, about 5 km short of runway. The aircraft was totally destroyed and all 16 occupants were killed.
Probable cause:
The accident was the direct result of poorly managed aircraft trajectory.
- The lack of vigilance with respect to altitude, by one pilot and then the other, when they were in a pilot-flying situation (PF, according to the Air Littoral Operations Manual) both when the aircraft descended out of the ILS beam through 2000 feet altitude and when it descended below 220 feet, the decision height.
- Inadequate coordination of tasks between the two pilots who formed the flight crew, neither of which had performed important tasks related to this function, such as monitoring and reporting ILS or altitude deviations, while in a nonpilot-flying situation (PNF, according to the same manual).
Final Report:

Crash of a Swearingen SA226TC Metro II in Washington-Dulles

Date & Time: Dec 18, 1987 at 1936 LT
Type of aircraft:
Operator:
Registration:
N23AZ
Survivors:
Yes
Schedule:
Newark - Washington DC
MSN:
TC-260
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7200
Captain / Total hours on type:
400.00
Aircraft flight hours:
12820
Circumstances:
The aircraft had descended through a cloud layer enroute for the scheduled landing at IAD and according to the crew had picked up some trace rime ice on its wing surfaces. Although pitot and sas (stall avoidance system) heat were used the captain elected not to use engine inlet anti-ice. Just inside the outer marker the left engine lost power followed shortly by the right engine. The captain was able to set the aircraft down in an open field where the gear collapsed during the landing roll. The engines were successfully run-up at the Garrett facility. The flight manual contains a warning and a note stating that engine heat and continuous ignition must be used after leaving icing conditions until the pilot is confident that any significant residual ice will not be ingested into the engines. Ice was found lying beneath the right wing which matched the curvature of the leading edge of the wing. A round conical shaped piece of ice was found along the wreckage path which matched the nose of the propeller spinner.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. All engines
2. (f) weather condition - icing conditions
3. (c) in-flight planning/decision - improper - pilot in command
4. (c) anti-ice/deice system - not used - pilot in command
5. (c) inadequate initial training - check pilot
6. (c) inadequate certification/approval, airman - company/operator mgmt
7. (f) wing, skin - ice
----------
----------
Occurrence #3: gear collapsed
Phase of operation: landing - flare/touchdown
Findings
8. (f) terrain condition - open field
9. (f) terrain condition - downhill
10. (f) light condition - dark night
Final Report:

Crash of a Lockheed C-130H Hercules off Vila dos Remédios: 29 killed

Date & Time: Dec 14, 1987 at 2130 LT
Type of aircraft:
Operator:
Registration:
2468
Survivors:
No
Schedule:
Recife – Vila dos Remédios
MSN:
4998
YOM:
1984
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
29
Circumstances:
The four engine aircraft was completing a flight from Recife to Vila dos Remédios, on Fernando de Noronha Island, carrying six crew of the Brazilian Air Force, two members of the Brazilian Navy, 13 local workers and huit island residents. The approach was initiated by night when the aircraft hit the water surface and crashed in the ocean about 16 km offshore. The aircraft was destroyed and all 29 occupants were killed.
Probable cause:
For unknown reasons, the crew was approaching the island at an insufficient altitude. Lack of visual references was considered as a contributing factor.

Crash of a BAe 3101 Jetstream 31 in Joplin

Date & Time: Dec 14, 1987 at 1358 LT
Type of aircraft:
Operator:
Registration:
N331PX
Survivors:
Yes
Schedule:
Memphis - Joplin
MSN:
700
YOM:
1986
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4864
Captain / Total hours on type:
414.00
Aircraft flight hours:
3470
Circumstances:
The captain stated that he had planned the approach at a higher-than-normal airspeed and altitude due to a reported low level windshear. At 400 feet agl the aircraft entered a light downdraft but the crew corrected the descent profile with power. At 200 feet agl the aircraft suddenly, according to the captain, pitched down before impacting the runway. Witnesses stated that the aircraft pitched down on short final, leveled off, then slammed onto the runway on all wheels. It then bounced, pitched down again and impacted the runway nose-first. A subsequent inspection, operational test, and teardown of the airplane's stall protection system found it to be functioning satisfactorily. The two powerplants also tested within normal parameters.
Probable cause:
Occurrence #1: loss of control - in flight
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (c) planned approach - improper - pilot in command
2. (c) compensation for wind conditions - inadequate - pilot in command
----------
Occurrence #2: hard landing
Phase of operation: landing - flare/touchdown
Findings
3. (c) flare - improper - pilot in command
4. Weather condition - windshear
5. Aborted landing - not performed - pilot in command
6. (f) recovery from bounced landing - improper - pilot in command
----------
Occurrence #3: complete gear collapsed
Phase of operation: landing - roll
Findings
7. (f) terrain condition - berm
Final Report:

Crash of a Short 360-330 near Iligan: 15 killed

Date & Time: Dec 13, 1987 at 0720 LT
Type of aircraft:
Operator:
Registration:
EI-BTJ
Survivors:
No
Site:
Schedule:
Cebu City - Iligan
MSN:
3719
YOM:
1987
Flight number:
PR443
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The crew started the approach to Iligan-Maria Cristina Airport in good weather conditions but the visibility was limited due to the night. On approach, the aircraft struck the slope of Mt Gurain located about 16 km south from runway 02 threshold. All 15 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Cessna 402B in Anchorage

Date & Time: Dec 9, 1987 at 1558 LT
Type of aircraft:
Operator:
Registration:
N969JW
Survivors:
Yes
Schedule:
Valdez - Anchorage
MSN:
402B-0328
YOM:
1972
Flight number:
8F304
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11495
Captain / Total hours on type:
1225.00
Aircraft flight hours:
5301
Circumstances:
During arrival in heavy traffic, Reeve flight 726 (Boeing 727) and Wilburs flight 304 (Cessna 402B, N969JW) received radar advisories for visual approaches to runways 06L and 06R, respectively. Subsequently, both flights were cleared to land. At 1555:04, the local tower controller transmitted that the wind at the approach end of runway 06R was from 340° at 9 knots and the midfield wind was 330° at 7 knots. At approximately 1557, flight 726 landed on runway 06L. Approximately 69 seconds later, as flight 304 was crossing the threshold (thr) of runway 06R at about 100 feet agl, the aircraft encountered wake turbulences (w/t) and rolled sharply to the right, byd 90°. The pilot corrected with aileron and power, but the aircraft lost altitude and hit the ground before recovery. The wind during the 1601 weather observation was 020° at 5 kts. Runway centerlines were 700 feet apart, threshold of runway 06L was 4,600 feet byd the threshold of runway 06R. The approach control did not advise either flight of the other's position, nor did the tower controller give a w/t advisory to flight 304. Calculations showed vortices could have drifted from runway 06L to runway 06R in as little as 28 seconds. FAA handbook addressed w/t advisory for parallel runway options with less than 2,500 feet separation, but did not address offset thresholds. All five occupants were injured.
Probable cause:
Occurrence #1: vortex turbulence encountered
Phase of operation: approach - vfr pattern - final approach
Findings
1. (f) light condition - dusk
2. (f) atc clearance - improper - atc personnel (dep/apch)
3. (f) unsafe/hazardous condition warning - not issued - atc personnel (lcl/gnd/clnc)
4. Condition(s)/step(s) insufficiently defined - faa (other/organization)
5. (c) in-flight planning/decision - improper - pilot in command
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: approach - vfr pattern - final approach
Final Report:

Crash of a Britten-Norman BN-2A-2 Islander in Kanabea: 1 killed

Date & Time: Dec 8, 1987
Type of aircraft:
Operator:
Registration:
P2-MIB
Flight Phase:
Survivors:
Yes
MSN:
217
YOM:
1970
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed shortly after takeoff for unknown reasons. A passenger was killed and three other occupants were injured.