Crash of a Fokker F27 Friendship 600 in Tarauacá

Date & Time: Oct 20, 2003 at 1132 LT
Type of aircraft:
Operator:
Registration:
PT-TVA
Survivors:
Yes
Schedule:
Cruzeiro do Sul – Tarauacá – Rio Branco
MSN:
10334
YOM:
1967
Flight number:
TVJ6167
Location:
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
3797.00
Copilot / Total hours on type:
2682
Aircraft flight hours:
55725
Aircraft flight cycles:
60270
Circumstances:
After landing at Tarauacá Airport, the crew started the braking procedure when control was lost. The aircraft veered off runway, collided with several obstacles and came to rest in a ditch. All 23 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing after the crew selected the power levers on 'ground fine pitch', combined with the failure of the antiskid system due to poor maintenance. The operator was facing enormous financial difficulties which affected the motivation of the maintenance, flight and cabin crew, which was considered as a contributing factor.
Final Report:

Crash of a BAe 3102 Jetstream 31 in Wick

Date & Time: Sep 17, 2003 at 1447 LT
Type of aircraft:
Operator:
Registration:
G-EEST
Survivors:
Yes
Schedule:
Aberdeen – Wick
MSN:
781
YOM:
1987
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1195.00
Copilot / Total flying hours:
6800
Copilot / Total hours on type:
1000
Aircraft flight hours:
17845
Aircraft flight cycles:
20730
Circumstances:
The aircraft was landing on Runway 31 at Wick Airport. It crossed the threshold at 130 kt which was 21 kt faster than the correct threshold speed. After the co-pilot closed the power levers the aircraft floated about six feet above the runway surface. The aircraft touched down and bounced before touching down a second time more heavily, cracking a wing spar and flexing the aircraft structure sufficient to allow the right propeller to contact the runway. The aircraft bounced again before touching down for the third and final time. The investigation determined that just before the first touchdown, one or both power levers were moved aft of the flight idle position. It was concluded that both the commander and co-pilot were making inputs on the flying controls from that moment onwards until after the second, heavy touchdown. There was no evidence of any technical fault on the aircraft and the weather conditions were well within the limitations set for the aircraft. No safety recommendations were made.
Probable cause:
It is reasonable to conclude that the manoeuvres conducted by G-EEST during the landing were the result of combined control inputs made by the commander and co-pilot. The evidence indicates that this period of combined control started at least 0.28 seconds before the first touchdown and finished at some stage after the second and damaging touchdown. After the first touchdown the aircraft became airborne in a high-drag, low-lift configuration which was intended for ground operation only and a 5.6g impact ensued on the second touchdown. There was no evidence of any technical fault on the aircraft that could have been a factor and the meteorological conditions were within the limitations set for the aircraft. A more complete understanding of the accident might have been possible with additional flight data parameters such as engine performance, aircraft pitch, and power lever position.
Final Report:

Crash of a Cessna 208B Grand Caravan near Summer Beaver: 8 killed

Date & Time: Sep 11, 2003 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FKAB
Survivors:
No
Schedule:
Pickle Lake - Summer Beaver
MSN:
208B-0305
YOM:
1992
Flight number:
WSG125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2351
Captain / Total hours on type:
946.00
Aircraft flight hours:
16770
Circumstances:
The aircraft departed Pickle Lake to Summer Beaver, Ontario, on a charter flight with seven passengers and one crew member. The flight proceeded on a direct routing to destination at 3500 feet above sea level under night visual flight conditions. On approaching Summer Beaver, the aircraft joined the circuit on a downwind leg for a landing on Runway 17. When the aircraft did not land, personnel at Summer Beaver contacted the Pickle Lake flight dispatch to inquire about the flight. The aircraft was declared missing following an unsuccessful radio search by the Pickle Lake flight dispatch staff. Search and rescue personnel found the wreckage in a wooded area three nautical miles northwest of Summer Beaver. The aircraft had been nearly consumed by a post-crash fire. All eight people on board had been fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
The aircraft departed controlled flight and struck terrain for undetermined reasons.
Findings as to Risk:
The company's flight-following procedures for flights operating in remote areas were impractical and were not consistently applied; this could compromise timely search and rescue operations following an accident.
Other Findings:
The aircraft did not carry flight recorders. Lack of information about the cause of this accident affects TSB's ability to identify related safety deficiencies and to issue safety communications intended to prevent accidents that could occur under similar circumstances.
Final Report:

Crash of a Let L-410UVP-E3 in Cap Haïtien: 21 killed

Date & Time: Aug 24, 2003 at 0457 LT
Type of aircraft:
Operator:
Registration:
HH-PRV
Flight Phase:
Survivors:
No
Schedule:
Cap Haïtien - Port-de-Paix
MSN:
87 20 01
YOM:
1987
Flight number:
TBG1301
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
8863
Captain / Total hours on type:
701.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
275
Aircraft flight hours:
2982
Aircraft flight cycles:
4154
Circumstances:
Shortly after a night takeoff from runway 05 at Cap Haïtien Airport, while in initial climb, the crew reported technical problems, declared an emergency and was cleared to return. While on base leg, the aircraft lost height and crashed in a sugar cane field located 2 km from the airport, bursting into flames. All 21 occupants were killed. It was later reported that the door of the forward baggage hold opened during takeoff.
Probable cause:
The accident was the consequence of a stall during approach while on the downwind leg base due to a loss of VMC at low altitude.
The following contributing factors were identified:
- Failure of the crew to manage the approach procedure (poor CRM),
- Use of maximum flaps (42°),
- Insufficient altitude,
- Lack of coordination between crew members,
- A possible state of fatigue of the captain,
- A possible overweight aircraft,
- The opening of the forward baggage hold door during takeoff.
Final Report:

Crash of a Cessna F406 Caravan II off Barrow: 2 killed

Date & Time: Aug 17, 2003 at 1256 LT
Type of aircraft:
Operator:
Registration:
N6591L
Flight Phase:
Survivors:
No
Schedule:
Barrow - Wainwright
MSN:
406-0053
YOM:
1990
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7000
Captain / Total hours on type:
1000.00
Aircraft flight hours:
7675
Circumstances:
The certificated airline transport pilot, with one non-revenue passenger, departed in the twin engine turboprop airplane from a rural airport on a CFR Part 135, VFR cargo flight over ocean waters. The flight did not reach its destination, and was reported overdue. Search personnel searched along the airplane's anticipated route of flight, over ocean waters. Shortly after initiation of the search, airborne search personnel reported sighting floating debris, consisting of what appeared to be aircraft seats, cardboard boxes, and small portions of aircraft wreckage, about 30.5 miles southwest of the flight's departure airport, and about 10 miles from shore. The airplane is presumed to have sunk in ocean waters estimated to be between 50 and 70 feet deep. Underwater search and recovery efforts were unsuccessful, and the airplane, pilot, and passenger remain missing. A review of archived radar data disclosed that as the accident airplane approached an area about 30.5 miles southwest of the departure airport, it descended to 500 feet msl, and then entered a right turn. As the turn progressed, the airplane continued to descend to 400 feet msl, with a radar-derived ground speed of 180 knots. The last radar return was recorded with the same radar-derived groundspeed, on an approximate heading of 200 degrees. A pilot who is familiar with geographical locations in the area reported that migrating whales are commonly sighted in the area where the radar depicted a descending right turn.
Probable cause:
An in-flight collision with ocean waters while maneuvering for an undetermined reason.
Final Report:

Crash of a Cessna 208B Grand Caravan in Tocomita: 1 killed

Date & Time: Aug 8, 2003 at 0932 LT
Type of aircraft:
Operator:
Registration:
YV-1069C
Survivors:
Yes
Schedule:
Porlamar - Canaima
MSN:
208B-0713
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
En route from Porlamar to Canaima, the crew informed ATC about engine problems and was cleared to divert to Tocomita for an emergency landing. On final approach, the aircraft stalled and crashed into trees 100 meters short of runway. A passenger was killed while 15 other occupants were injured. The aircraft was destroyed.

Crash of a Cessna 402C off Treasure Cay: 2 killed

Date & Time: Jul 13, 2003 at 1530 LT
Type of aircraft:
Operator:
Registration:
N314AB
Survivors:
Yes
Schedule:
Fort Lauderdale – Treasure Cay
MSN:
402C-0413
YOM:
1980
Flight number:
RSI502
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7904
Captain / Total hours on type:
4964.00
Aircraft flight hours:
17589
Circumstances:
On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, following the in-flight failure of the right engine. Four of the nine passengers sustained no injuries, three passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 135 as a scheduled international passenger commuter flight from Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida, to MYAT. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan.
Probable cause:
The in-flight failure of the right engine and the pilotís failure to adequately manage the airplaneís performance after the engine failed. The right engine failure resulted from inadequate maintenance that was performed by Air Sunshine's maintenance personnel during undocumented maintenance. Contributing to the passenger fatalities was the pilotís failure to provide an emergency briefing after the right engine failed.
Final Report:

Crash of a Boeing 737-2J8C in Port Sudan: 116 killed

Date & Time: Jul 8, 2003 at 0417 LT
Type of aircraft:
Operator:
Registration:
ST-AFK
Survivors:
Yes
Schedule:
Port Sudan - Khartoum
MSN:
21169
YOM:
1975
Flight number:
SD139
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
106
Pax fatalities:
Other fatalities:
Total fatalities:
116
Circumstances:
The aircraft departed Port Sudan Airport at 0407LT on a schedule service to Khartoum with 105 passengers and 11 crew members on board. During climbout, the crew informed ATC about technical problems and was cleared to return for an emergency landing on runway 33. On final approach in limited visibility, the aircraft struck the ground and crashed about 5 km from the runway threshold. The aircraft was totally destroyed by impact forces. A boy aged two was injured while 116 other occupants were killed, among them eight EU citizens and one high ranking officer of the Sudan Army.
Probable cause:
Failure of one engine during initial climb for unknown reasons.

Crash of a Canadair RegionalJet CRJ-100ER in Brest: 1 killed

Date & Time: Jun 22, 2003 at 2351 LT
Operator:
Registration:
F-GRJS
Survivors:
Yes
Schedule:
Nantes - Brest
MSN:
7377
YOM:
2000
Flight number:
AF5672
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16000
Captain / Total hours on type:
5300.00
Copilot / Total flying hours:
4800
Copilot / Total hours on type:
650
Aircraft flight hours:
6649
Aircraft flight cycles:
6552
Circumstances:
On Sunday 22 June 2003, the CRJ-100 registered F-GRJS was operating as scheduled flight AF 5672 between Nantes Atlantique and Brest-Guipavas aerodromes (France) under an IFR flight plan. The flight represented the last leg of a Brest – Nantes – Strasbourg – Nantes – Brest rotation. The aeroplane was operated by Brit Air on behalf of Air France. The Captain was pilot flying (PF). The crew also included another pilot (the co-pilot), and one cabin crew. The aeroplane took off at 21 h 16 (2) with twenty-one passengers. The flight was approximately fifty minutes late, due to a delay in the first flight of the day that had affected the subsequent flights. During the flight, with the authorisation of the control centre, the crew passed northeast of the planned track in order to avoid cumulonimbus formations. At Brest Guipavas, the 21 h 00 ATIS indicated visibility of eight hundred meters with some fog and a cloud base at two hundred feet with the presence of cumulonimbus. The runway in use was 26 Left with an ILS approach. Runway use was temporarily restricted to Cat I due to presence of works. At 21 h 36 min 27 s, the flight (radio call sign BZ 672 EC) was cleared by the enroute controller to descend to Flight Level 150 then, at 21 h 39 min 10 s, to Flight Level 70. At 21 h 39 min 23 s, the crew announced that they were descending to Flight Level 70 towards BODIL, the initial approach fix, avoiding storms. At 21 h 39 min 31 s, the Brest approach controller transmitted "Descend four thousand feet QNH one thousand and eight, number two on approach, plan a holding pattern at Golf Uniform". At 21 h 44 min 21 s, the controller cleared descent to three thousand feet and added "and perform a holding pattern". The aeroplane was approximately 20 NM DME from BG. At 21 h 47 min 40 s, that is, approximately one-and-a-half-minutes before the planned start of the hold, the controller cleared descent to two thousand feet QNH. At 21 h 48 min 01 s, the controller announced "Echo Charlie, preceding aeroplane has landed, continue the approach, report at Outer Marker". Four seconds later, at 9.4 NM DME, the autopilot "Heading" and "Vertical Speed" modes became active and the aeroplane adopted a heading of 257°. The Brest ILS frequency was displayed on the VOR 1 and the VOR navigation source was selected. At 21 h 48 min 21 s, the controller called back "Are you ready for the approach?". The crew confirmed and the controller asked "Report at Outer Marker". The Copilot read this back. At the Captain’s request, the Co-pilot extended the flaps to 20° then the landing gear. The aeroplane stabilized at two thousand feet QNH on autopilot, still in Heading mode, at about 7 NM DME. Simultaneously, the wind, which had started to veer northwest during the descent, caused the aeroplane to drift towards the left. The flight crew did not notice this drift. At 21 h 49 min, the co-pilot extended the flaps to 30° then to 45° and the crew performed the pre-landing checklist. At 21 h 49 min 35 s, the controller cleared the landing for runway 26 Left and indicated a cloud base of less than one hundred feet. At 21 h 49 min 40 s, the aeroplane, in level flight, passed under then above the glide slope. At 21 h 50 min, the aeroplane passed the GU beacon, slightly to the left, with a track deviating to the left in relation to the localizer centreline. At that moment, the wind calculated by the Flight Management System (FMS) was 300° / 20 kt. A short time later, the aeroplane began its descent. The aeroplane continued to drift to the left of the localizer centreline. At 21 h 50 min 45 s the aeroplane again passed through the glide slope, and the Captain said "Approach selected, LOC and Glide"; the Co-pilot confirmed. The autopilot "heading" and "vertical speed" modes remained active. The aeroplane thereafter remained below the glide slope for the remainder of the flight. Between 21 h 50 min 58 s and 21 h 51 min 02 s, the GPWS announced, successively, "Five hundred", "Glide slope" then "Sink rate". At 21 h 51 min 01 s, the aeroplane began a turn to the right. By this time, the aeroplane was 4.68 points to the left of the localizer centreline. At 21 h 51 min 04 s, the Captain disengaged the autopilot. At 21 h 51 min 05 s, the GPWS announced "Three hundred". Between 21 h 51 min 07 s and 21 h 51 min 14 s, seven "Glide slope" alarms sounded. During this time, the Co-pilot said "come right" on two occasions and the aeroplane attitude changed from - 5° to 0°. At 21 h 51 min 15 s, the GPWS announced "One hundred". At 21 h 51 min 16 s, with the aeroplane at 529 feet QNH and 93 feet on the radio altimeter, the Co-pilot said "I’ve got nothing in front", then the Captain said "Go around". Simultaneously, the engine thrust increased significantly. The aeroplane attitude returned to - 5 in four seconds. At 21 h 51 min 19 s, the Co-pilot said "Go around". At 21 h 51 min 20 s, the GPWS announced "Sink rate" then "Pull up". The Co-pilot said "Go around" again at 21 h 51 min 22. The first sounds of the impact were recorded by the CVR at 21 h 51 min 22 s, and the recording stopped at 21 h 51 min 24. s. The aeroplane, which touched the ground without any great force, rolled, struck several obstacles and ended up 450 meters left of the extended runway centreline, 2,150 meters from the runway threshold. The Captain was killed. The rest of the crew and the passengers managed to evacuate the aeroplane, which was destroyed by fire.
Probable cause:
The causes of the accident are as follows:
• neglecting to select the APPR mode at the start of the approach, which led to non-capture of the localizer then of the glide slope;
• partial detection of flight path deviations, due to the crew’s focusing on vertical navigation then on horizontal navigation;
• continuing a non-stabilised approach down to the decision altitude.
Lack of communication and coordination in the cockpit, and a change of strategy on the part of the Controller in managing the flight were contributing factors.
Final Report:

Crash of a Fokker 50 in Adar Yeil

Date & Time: Jun 16, 2003 at 0630 LT
Type of aircraft:
Operator:
Registration:
ST-ARA
Survivors:
Yes
Schedule:
Khartoum - Adar Yeil
MSN:
20154
YOM:
1989
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on a gravel runway at Adar Yeil Airport, the aircraft collided with a flock of birds, damaging the left engine. The aircraft went out of control and veered to the left, causing the left propeller to struck the ground. The propeller blades separated, punctured the fuselage and injured three passengers. The aircraft came to a halt and all occupants evacuated. The aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing following a collision with a flock of birds.