Crash of a De Havilland DHC-6 Twin Otter 200 in Fort Franklin: 7 killed

Date & Time: Oct 9, 1984 at 1730 LT
Registration:
C-FPPL
Survivors:
No
Schedule:
Fort Norman - Fort Franklin
MSN:
115
YOM:
1968
Flight number:
NAS097
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
7
Aircraft flight hours:
23645
Circumstances:
The aircraft departed Fort Norman at 16:51 and arrived overhead Fort Franklin at approximately 17:15. Because Fort Franklin was shrouded in fog, a local resident contacted the pilot on a portable VHF transceiver and advised him that there was little or no visibility. The pilot replied that he did not think he would be able to land. The resident drove to the airstrip and contacted the pilot again when he heard the aircraft returning. He advised the pilot that visibility was 200-300 feet. The pilot then asked if this was the vertical or horizontal visibility. At that moment the Twin Otter struck a 200-foot-high telecommunications tower while in controlled level fight. Part of the right wing broke off and the aircraft slowly rolled over before striking the ground. The decision of the pilot to continue the approach in foggy weather were possibly influenced by the effects of stress and a greater than usual personal need to complete the flight. The stress was probably caused by the fact that the pilot had been involved in four accidents since March 1984. Although he was a very experienced pilot, his previous employer terminated his employment on 31 August 1984. In their opinion, his ability to make operational decisions was in question. The pilot was hired by Nahanni Air Services one month later.
Probable cause:
The following findings were reported:
- The weather at Fort Franklin was unsuitable for the flight,
- The flight was continued into weather below that which is required for VFR flight,
- An approach to the aerodrome was attempted using the radar altimeter to provide terrain clearance,
- The pilot descended to an altitude below the height of the telecommunications tower,
- A lack of official weather observations and of communications facilities at Fort Franklin deprived the pilot of reliable local weather information on which to base his decisions,
- There exists in the more remote areas of Canada a different attitude with regard to the assessment of risk in flight operations; it is likely that this attitude influenced the decisions and actions of the pilot,
- The operational decisions of the pilot may have been influenced by the effects of stress and a greater than usual personal need to complete the flight,
- Company management may have had a better appreciation of the risk potential associated with the recent events in the pilot's life, if they had more awareness of the effects of stress on performance.

Crash of a PZL-Mielec AN-2R near Sredniye Kalar

Date & Time: Oct 6, 1984
Type of aircraft:
Operator:
Registration:
CCCP-55763
Flight Phase:
Survivors:
Yes
MSN:
1G50-16
YOM:
1964
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route, the engine failed due to carburetor icing. The crew attempted an emergency landing in the taïga. There were no casualties while the aircraft was damaged beyond repair.
Probable cause:
Engine failure in-flight after the carburetor failed due to icing.

Crash of a Piper PA-31T3-T1040 Cheyenne in Atlanta

Date & Time: Sep 24, 1984 at 1609 LT
Type of aircraft:
Registration:
N9193Y
Survivors:
Yes
Schedule:
Florence - Atlanta
MSN:
31T-8275010
YOM:
1982
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3309
Captain / Total hours on type:
439.00
Aircraft flight hours:
1857
Circumstances:
The normal fuel load for the flight was 1,500 lbs, but with a forecast tail wind and an estimated flight time for only 1+10, the crew accepted the lower indicated (950 lb) fuel load. The flight was uneventful until an indication of 250 lbs per side, then the fuel 'seemed to dissipate faster.' With an indication of 150 lbs on downwind, the copilot recommended declaring an emergency. The captain's response was to ask ATC for the anticipated length of the downwind leg. He was told 20 miles. Priority handling was requested, but was only available for a declared emergency. The approach was continued with normal handling for approximately 10 minutes. At 1608:39, the crew declared an emergency, then reported the aircraft was out of fuel. It crash landed on rough terrain, short of runway 08. An exam revealed fuel sensors had been improperly installed (interchanged between the inboard and outboard tanks). Thus the gages indicated about 180 lbs more than the approximately 763 lbs that was actually aboard at takeoff. A special 500 hour inspection of the entire fuel system was made on 7/8/84 using the 'wet' method, but only the capacitance method checks each individual sensor. All 11 occupants were injured and the aircraft was destroyed.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: approach - faf/outer marker to threshold (ifr)
Findings
1. (f) fuel system - incorrect
2. (f) maintenance, installation - improper
3. (f) engine instruments, fuel quantity gage - false indication
4. Maintenance, inspection - inadequate
5. (f) procedure inadequate - manufacturer
6. (f) fluid, fuel - low level
7. (c) in-flight planning/decision - improper - pilot in command
8. (c) remedial action - delayed - pilot in command
9. (c) fluid, fuel - exhaustion
10. Fuel supply - inadequate
----------
Occurrence #2: forced landing
Phase of operation: approach - faf/outer marker to threshold (ifr)
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
11. (f) terrain condition - rough/uneven
Final Report:

Crash of a Swearingen SA226TC Metro II in Vienna

Date & Time: Sep 17, 1984
Type of aircraft:
Registration:
OE-LSA
Survivors:
Yes
MSN:
TC-315
YOM:
1979
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
For unknown reasons, the twin engine aircraft belly landed at Vienna-Schwechat Airport. All 11 occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Handley Page HPR.7 Dart Herald 202 in Kandala: 30 killed

Date & Time: Sep 11, 1984
Registration:
9Q-CAH
Survivors:
Yes
Schedule:
Kinshasa – Tshikapa
MSN:
159
YOM:
1962
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
31
Pax fatalities:
Other fatalities:
Total fatalities:
30
Circumstances:
En route from Kinshasa to Tshikapa, one of the engine failed. The crew decided to divert to Kandala Airstrip, southeast of Bandundu province. After landing on a small airfield, the aircraft was unable to stop within the remaining distance, overran and crashed in flames. Six passengers were injured while 30 other occupants were killed.
Probable cause:
Engine failure in flight for unknown reasons.

Crash of a Cessna 402C in Naples: 1 killed

Date & Time: Sep 7, 1984 at 2110 LT
Type of aircraft:
Operator:
Registration:
N89PB
Flight Phase:
Survivors:
Yes
Schedule:
Naples - Tampa
MSN:
402C-0650
YOM:
1982
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2639
Captain / Total hours on type:
412.00
Aircraft flight hours:
1495
Circumstances:
Shortly after takeoff, both engines lost power and a wheels up landing was made in an open field. The aircraft was destroyed by impact and fire. An investigation revealed that the aircraft had been refuel with Jet-A fuel rather than 100 low lead avgas. The lineman had inadvertently used the Jet-A fuel truck which was identical to the Avgas truck except for a decal, appx 4' by 16', which identified the type of fuel. The lineman stated that his training consisted of approximately 30 minutes of reading the company maintenance manual on how to refuel the different company aircraft, then was given on-the-job training for a brief time. When he went to refuel N89PB prior to the accident flight, he went to the parking space where the Avgas truck was normally parked, but on that occasion, the Jet-A fuel truck was there.
Probable cause:
Occurrence #1: loss of engine power (total) - nonmechanical
Phase of operation: climb - to cruise
Findings
1. (c) fluid, fuel grade - improper
2. (c) maintenance, service of aircraft/equipment - improper - ground personnel
3. (f) habit interference - ground personnel
4. (f) inadequate surveillance, inadequate procedure - company/operator mgmt
----------
Occurrence #2: forced landing
Phase of operation: landing - flare/touchdown
----------
Occurrence #3: in flight collision with terrain/water
Phase of operation: landing - flare/touchdown
Findings
5. Terrain condition - rough/uneven
6. Wheels up landing - performed - pilot in command
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander on Mt Musaka: 9 killed

Date & Time: Sep 6, 1984
Type of aircraft:
Operator:
Registration:
P2-ISG
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Wewak – Tabubil – Telefomin – Kiunga
MSN:
756
YOM:
1975
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
En route from Tabubil to Telefomin, the twin engine aircraft crashed in unknown circumstances on Mt Musaka. Two passengers were seriously injured while 9 other occupants were killed.

Ground explosion of a Boeing 737-2H7C in Douala: 2 killed

Date & Time: Aug 30, 1984
Type of aircraft:
Operator:
Registration:
TJ-CBD
Flight Phase:
Survivors:
Yes
Schedule:
Douala – Yaoundé – Garoua
MSN:
21295
YOM:
1977
Flight number:
UY786
Location:
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
109
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While taxiing at Douala Airport, an explosion occurred on the left hand side. The crew stopped the aircraft on the taxiway and started an emergency evacuation. 94 occupants were wounded while 20 others were uninjured. Unfortunately, two passengers died by asphyxia.
Probable cause:
It was reported by the Cameroon Authorities that a bomb placed in the left main wheel well exploded during taxi, causing a rupture of the main left fuel tank. A fire erupted, partially destroying the aircraft. It appears that the bomb was placed by members of the 'Liberation Front of Cameroon'.

Crash of a Beechcraft C99 Airliner near San Luis Obispo: 15 killed

Date & Time: Aug 24, 1984 at 1118 LT
Type of aircraft:
Operator:
Registration:
N6399U
Flight Phase:
Survivors:
No
Schedule:
Los Angeles – Santa Maria – San Luis Obispo – San Francisco
MSN:
U-187
YOM:
1982
Flight number:
RM628
Crew on board:
2
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
4110
Captain / Total hours on type:
873.00
Copilot / Total flying hours:
6194
Copilot / Total hours on type:
62
Circumstances:
Wings West Airlines Flight 628, a commuter flight, departed Los Angeles for San Francisco, with scheduled en route stops at Santa Maria and San Luis Obispo. At 11:10, Flight 628 left the gate at San Luis Obispo. The weather at the time was essentially clear and the visibility was 15 miles. At 11:16, after taking off from runway 29, Flight 628 called the Los Angeles ARTCC and reported that it was climbing through 2,700 feet 'IFR to San Francisco.' At 11:17:23, the Los Angeles ARTCC’s radar controller cleared Flight 628 to the San Francisco airport, as filed, to climb and maintain 7,000 feet. At 11:17:38 the aircraft collided head-on with Rockwell Commander N112SM at 3,400 feet. This single-engined aircraft had departed Paso Robles Airport on a training flight with two pilots on board. Nll2SM was flying in visual meteorological conditions and under VFR in the vicinity of the San Luis Obispo Airport just before the collision.
Probable cause:
The failure of the pilots of both aircraft to follow the recommended communications and traffic advisory practices for uncontrolled airports contained in the Airman’s Information Manual to alert each other to their presence and to enhance the controller’s ability to provide timely traffic advisories. Underlying the accident were the physiological limitations of human vision and reaction time. Also underlying the accident was the short time available to the controller to detect and appraise radar data and to issue a safety advisory. Contributing to the accident was the Wings West Airlines policy which required its pilots to tune one radio to the company frequency at all times.
Final Report: