Crash of a Piper PA-31-350 Navajo Chieftain off Whyalla: 8 killed

Date & Time: May 31, 2000 at 1905 LT
Operator:
Registration:
VH-MZK
Survivors:
No
Schedule:
Adelaide - Whyalla
MSN:
31-8152180
YOM:
1981
Flight number:
WW904
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2211
Captain / Total hours on type:
113.00
Aircraft flight hours:
11837
Circumstances:
On the evening of 31 May 2000, Piper Chieftain, VH-MZK, was being operated by Whyalla Airlines as Flight WW904 on a regular public transport service from Adelaide to Whyalla, South Australia. One pilot and seven passengers were on board. The aircraft departed at 1823 central Standard Time (CST) and, after being radar vectored a short distance to the west of Adelaide for traffic separation purposes, the pilot was cleared to track direct to Whyalla at 6,000 ft. A significant proportion of the track from Adelaide to Whyalla passed over the waters of Gulf St Vincent and Spencer Gulf. The entire flight was conducted in darkness. The aircraft reached 6,000 ft and proceeded apparently normally at that altitude on the direct track to Whyalla. At 1856 CST, the pilot reported to Adelaide Flight Information Service (FIS) that the aircraft was 35 NM south-south-east of Whyalla, commencing descent from 6,000 ft. Five minutes later the pilot transmitted a MAYDAY report to FIS. He indicated that both engines of the aircraft had failed, that there were eight persons on board and that he was going to have to ditch the aircraft, but was trying to reach Whyalla. He requested that assistance be arranged and that his company be advised of the situation. About three minutes later, the pilot reported his position as about 15 NM off the coast from Whyalla. FIS advised the pilot to communicate through another aircraft that was in the area if he lost contact with FIS. The pilot’s acknowledgment was the last transmission heard from the aircraft. A few minutes later, the crew of another aircraft heard an emergency locater transmitter (ELT) signal for 10–20 seconds. Early the following morning, a search and rescue operation located two deceased persons and a small amount of wreckage in Spencer Gulf, near the last reported position of the aircraft. The aircraft, together with five deceased occupants, was located several days later on the sea–bed. One passenger remained missing.
Probable cause:
Engine operating practices:
• High power piston engine operating practices of leaning at climb power, and leaning to near ‘best economy’ during cruise, may result in the formation of deposits on cylinder and piston surfaces that could cause preignition.
• The engine operating practices of Whyalla Airlines included leaning at climb power and leaning to near ‘best economy’ during cruise.
Left engine:
The factors that resulted in the failure of the left engine were:
• The accumulation of lead oxybromide compounds on the crowns of pistons and cylinder head surfaces.
• Deposit induced preignition resulted in the increase of combustion chamber pressures and increased loading on connecting rod bearings.
• The connecting rod big end bearing insert retention forces were reduced by the inclusion, during engine assembly, of a copper–based anti-galling compound.
• The combination of increased bearing loads and decreased bearing insert retention forces resulted in the movement, deformation and subsequent destruction of the bearing inserts.
• Contact between the edge of the damaged Number 6 connecting rod bearing insert and the Number 6 crankshaft journal fillet resulted in localised heating and consequent cracking of the nitrided surface zone.
• Fatigue cracking in the Number 6 journal initiated at the site of a thermal crack and propagated over a period of approximately 50 flights.
• Disconnection of the two sections of the journal following the completion of fatigue cracking in the journal and the fracture of the Number 6 connecting rod big end housing most likely resulted in the sudden stoppage of the left engine.
Right engine:
The factors that were involved in the damage/malfunction of the right engine following the left engine malfunction/failure were:
• Detonation of combustion end-gas.
• Disruption of the gas boundary layers on the piston crowns and cylinder head surface increasing the rate of heat transfer to these components.
• Increased heat transfer to the Number 6 piston and cylinder head resulted in localised melting.
• The melting of the Number 6 piston allowed combustion gases to bypass the piston rings.
The flight:
The factors that contributed to the flight outcome were:
• The pilot responded to the failed left engine by increasing power to the right engine.
• The resultant change in operating conditions of the right engine led to loss of power from, and erratic operation of, that engine.
• The pilot was forced to ditch the aircraft into a 0.5m to 1m swell in the waters of Spencer Gulf, in dark, moonless conditions.
• The absence of upper body restraints, and life jackets or flotation devices, reduced the chances of survival of the occupants.
• The Emergency Locator Transmitter functioned briefly on impact but ceased operating when the aircraft sank.
Final Report:

Crash of a Swearingen SA226TC Metro II in Bocas del Toro

Date & Time: May 10, 2000 at 1009 LT
Type of aircraft:
Operator:
Registration:
HP-1364MAM
Survivors:
Yes
MSN:
TC-324
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Bocas del Toro, in unclear circumstances, the aircraft went out of control and veered off runway. It lost its undercarriage and came to rest in a sugarcane field. All eight occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Britten-Norman BN-2A-20 Islander in Bapi: 4 killed

Date & Time: Apr 29, 2000
Type of aircraft:
Operator:
Registration:
P2-ISA
Flight Phase:
Survivors:
No
MSN:
703
YOM:
1973
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Shortly after takeoff from the Bapi grassy runway 14/32 which is 495 metres long, the twin engine aircraft collided with trees and crashed, bursting into flames. All four occupants were killed. It is believed that the pilot completed the rotation too late.

Crash of an Avro RJ70 in Siirt

Date & Time: Apr 22, 2000 at 1405 LT
Type of aircraft:
Operator:
Registration:
TC-THL
Survivors:
Yes
Schedule:
Ankara – Siirt
MSN:
E1249
YOM:
1996
Flight number:
TK774
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7200
Aircraft flight cycles:
6200
Circumstances:
Following an uneventful flight from Ankara, the aircraft landed at Siirt Airport runway 24/06 which is 1,660 metres long. After touchdown on a wet runway, the aircraft was unable to stop within the remaining distance, overran and came to rest few dozen metres further. All 46 occupants evacuated safely while the aircraft was damaged beyond repair. All conditions were not met for a safe landing and the braking action was moderate to poor. Aquaplaning was suspected.

Crash of a Boeing 737-200 in Davao City: 131 killed

Date & Time: Apr 19, 2000 at 0701 LT
Type of aircraft:
Operator:
Registration:
RP-C3010
Survivors:
No
Schedule:
Manila - Davao City
MSN:
21447
YOM:
1978
Flight number:
2P541
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
124
Pax fatalities:
Other fatalities:
Total fatalities:
131
Aircraft flight hours:
68475
Aircraft flight cycles:
79522
Circumstances:
The aircraft was being flown as a route check for for a captain. Another captain was acting as Pilot Monitoring on the flight. The en route part of the flight was uneventful. The aircraft was conducting an ILS approach to runway 05 and the controller reported that they would be behind Philippine Airlines flight 809, an Airbus A319. As the Boeing 737 broke out of clouds, the A319 was observed on runway 05. The Pilot Flying informed ATC of his intention to perform a 360° maneuver, but the Pilot Monitoring advised ATC of the opposite, stating that the aircraft would turn right instead of following the missed approach procedure, which called for a left hand turn to a 020° heading. The aircraft re-entered clouds and attempted to fly visually at a lower altitude in instrument conditions when in fact it should have climbed to 4,000 feet. The flight continued over Samal Island and the flight requested a VOR/DME approach and landing in the opposite direction (runway 23), which was approved by the controller. After having aligned with the runway heading, the aircraft descended below the normal glide path for this approach. It continued down to 570 feet at a point where the aircraft should have been at 1,500 feet. The aircraft crashed into a coconut plantation on a hillside in Barangay San Isidro, disintegrated and caught fire. All 131 occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Saab 340B in Killeen

Date & Time: Mar 21, 2000 at 1914 LT
Type of aircraft:
Operator:
Registration:
N353SB
Survivors:
Yes
Schedule:
Dallas - Killeen
MSN:
353
YOM:
1993
Flight number:
AA3789
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12518
Captain / Total hours on type:
9251.00
Copilot / Total flying hours:
2105
Copilot / Total hours on type:
1040
Aircraft flight hours:
11976
Circumstances:
The captain was the flying pilot for the night landing on runway 01 in instrument meteorological conditions (IMC), with a right cross wind from 110 degrees at 14 gusting 18 knots, drizzle, and a wet runway. Prior to starting the approach, the flightcrew determined that the landing approach speed (Vref) and the approach speed (Vapp) were 122 and 128 knots, respectively. DFDR data showed the airplane flying on autopilot as it passed the middle marker at 200 feet AGL at 130 knots on the ILS approach. Approximately 3 seconds after the first officer called "runway in sight twelve o'clock," the captain disconnected the autopilot, while at a radio altitude of 132 feet and on a heading of approximately 18 degrees. Within approximately 11 seconds after the autopilot disconnect, the glideslope and localizer deviation increased. The first officer called "runway over there." Approximately 5 seconds before touchdown, the airplane rolled right, then left, then right. DFDR data-based performance calculations showed the airplane crossed the threshold at an altitude of 35 feet and 130 knots. The airplane touched down 2,802 feet from the approach end of the 5,495-foot runway (844- foot displaced threshold) at 125 knots on a heading of 10 degrees. The airplane overran the runway and struck a ditch 175 feet beyond the departure end of the runway. Landing roll calculations showed a ground roll of 2,693 feet after touchdown, consisting of 1,016 feet ground roll before braking was initiated and 1,677 feet ground roll after braking was initiated until the airplane exited the pavement. According to Saab, for a wet runway, the aircraft would have needed 1,989 feet from the time of braking initiation to come to a complete stop. The American Eagle Airlines, Inc., FAA approved aircraft operating manual (AOM), states in part: Stabilized approaches are essential when landing on contaminated runways. Landing under adverse weather conditions, the desired touch-down point is still 1,000 feet from the approach end of the runway. Touchdown at the planned point. Cross the threshold at Vapp, then bleed off speed to land approximately Vref -5. Use reverse, if needed. To achieve maximum braking effect on wet runway, apply maximum and steady brake pressure. In 1992, the City of Killeen submitted a proposal that included extending the north end of runway 01 by 194 feet. The FAA originally disapproved the proposal, in part, because the runway extension decreased the length of the runway safety area (RSA) which was already shorter than the recommended 1,000 feet for a 14 CFR Part 139 certificated airport. The proposal was subsequently approved and a drainage ditch was installed in the north RSA, perpendicular to the runway and approximately 175 feet north of the departure end of runway 01. In 1993, the airport received FAA Part 139 certification. The 1998 and 1999, FAA airport certification inspection reports noted the inadequate RSA; however, neither letter of correction, sent from the FAA to the City of Killeen following the inspections, mentioned the RSA. Following this accident, the ILS runway 01 was flight checked by the FAA and all components were found to be operating within prescribed tolerances. Examination of the airplane found no anomalies that would have prevented it from operating per design prior to departing the runway and encountering the ditch.
Probable cause:
The captain's failure to follow standard operating procedure for landing on a contaminated runway in that he touched down long, which combined with his delayed braking resulted in a runway overrun. Contributing factors were the captain's failure to maintain runway alignment following his disconnect of the autopilot, the gusty crosswind and the wet runway. In addition, the following were contributing factors:
(1) the airport operator's failure to fill in a ditch in the runway safety area,
(2) the FAA's granting of 14 CFR Part 139 approval to the airport when the runway safety area (RSA) did not meet the recommended length for a Part 139 airport, and
(3) the FAA's continued lack of acknowledgement to the airport of the inadequate RSA following their annual airport inspection checks.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Carreto: 10 killed

Date & Time: Mar 17, 2000 at 0930 LT
Operator:
Registration:
HP-1267APP
Flight Phase:
Survivors:
No
Site:
Schedule:
Panama City - Puerto Obaldía
MSN:
624
YOM:
1979
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
While descending at an altitude of 7,500 feet in relative good weather conditions, the crew informed ATC about their position when contact was lost. The wreckage was found five days later at the altitude of 762 metres on the slope of a mountain (850 metres high) located near Carreto, about 22 km northwest pf Puerto Obaldía Airport. All 10 occupants were killed. The crew was descending under VFR mode when the accident occurred for unknown reasons.

Crash of a Boeing 737-3T5 in Burbank

Date & Time: Mar 5, 2000 at 1811 LT
Type of aircraft:
Operator:
Registration:
N668SW
Survivors:
Yes
Schedule:
Las Vegas - Burbank
MSN:
23060
YOM:
1984
Flight number:
WN1455
Crew on board:
5
Crew fatalities:
Pax on board:
137
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11000
Captain / Total hours on type:
9870.00
Copilot / Total flying hours:
5022
Copilot / Total hours on type:
2522
Circumstances:
On March 5, 2000, about 1811 Pacific standard time (PST), Southwest Airlines, Inc., flight 1455, a Boeing 737-300 (737), N668SW, overran the departure end of runway 8 after landing at Burbank-Glendale-Pasadena Airport (BUR), Burbank, California. The airplane touched down at approximately 182 knots, and about 20 seconds later, at approximately 32 knots, collided with a metal blast fence and an airport perimeter wall. The airplane came to rest on a city street near a gas station off of the airport property. Of the 142 persons on board, 2 passengers sustained serious injuries; 41 passengers and the captain sustained minor injuries; and 94
passengers, 3 flight attendants, and the first officer sustained no injuries. The airplane sustained extensive exterior damage and some internal damage to the passenger cabin. During the accident sequence, the forward service door (1R) escape slide inflated inside the airplane; the nose gear collapsed; and the forward dual flight attendant jump seat, which was occupied by two flight attendants, partially collapsed. The flight, which was operating on an instrument flight rules flight plan, was conducted under 14 Code of Federal Regulations (CFR) Part 121. Visual meteorological conditions (VMC) prevailed at the time of the accident, which occurred
in twilight lighting conditions.
Probable cause:
The flight crew's excessive airspeed and flightpath angle during the approach and landing and its failure to abort the approach when stabilized approach criteria were not met. Contributing to the accident was the controller's positioning of the airplane in such a manner as to leave no safe options for the flight crew other than a go-around maneuver.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Stony Rapids

Date & Time: Feb 27, 2000 at 2200 LT
Operator:
Registration:
C-FATS
Survivors:
Yes
Schedule:
Edmonton - Stony Rapids
MSN:
31-7952072
YOM:
1979
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
1450.00
Circumstances:
The Piper Navajo Chieftain PA-31-350, serial number 31-7952072, departed Edmonton, Alberta, on an instrument flight rules charter flight to Stony Rapids, Saskatchewan, with one pilot and six passengers on board. The pilot conducted a non-directional beacon approach at night in Stony Rapids, followed by a missed approach. He then attempted and missed a second approach. At about 2200 central standard time, while manoeuvring to land on runway 06, the aircraft struck trees 3.5 nautical miles west of the runway 06 button and roughly one quarter nautical mile left of the runway centreline, at an altitude of 1200 feet above sea level. The aircraft sustained substantial damage, but no fire ensued. The pilot and one passenger were seriously injured, and the remaining five passengers sustained minor injuries. Canadian Forces search and rescue specialists were air-dropped to the site at 0300 and provided assistance to the pilot and passengers. Local ground search parties later assisted with the rescue.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The pilot executed a missed approach on his first NDB approach, and, during the second missed approach, after momentarily seeing the runway, he decided to conduct a visual approach, descending below MDA in an attempt to fly under the cloud base.
2. In flying under the cloud base during the visual portion of his approach, the pilot likely perceived the horizon to be lower on the windscreen than it actually was.
3. There was no indication that there was any form of pressure from management to influence the pilot to land at the destination airport. However, the pilot may have chosen to land in Stony Rapids because he had an early flight the following day, and he did not have the keys for the accommodations in Fond-du-Lac.
Findings as to Risk:
1. No scale was available to the pilot in Edmonton for weighing aircraft loads.
2. The maximum allowable take-off weight of the aircraft was exceeded by about 115 pounds, and it is estimated that at the time of the crash, the aircraft was 225 pounds below maximum landing weight. The aircraft's centre of gravity was not within limits at the time of the crash.
3. The rear baggage area contained 300 pounds of baggage, 100 pounds more than the manufacturer's limitation.
4. Two screws were missing from each section of the broken seat track to which the anchor points were attached.
5. Cargo net anchorage system failure contributed to passenger injuries.
6. The stitching failed on the seat belt's outboard strap that was mounted on the right, middle, forward-facing cabin seat.
Other Findings:
1. Hand tools were required to access the ELT panel, since the cockpit remote switch could not be accessed.
Final Report:

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

Date & Time: Feb 21, 2000 at 1123 LT
Type of aircraft:
Operator:
Registration:
N219CS
Survivors:
Yes
Schedule:
Point Lay - Kotzebue
MSN:
31-8275005
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
13500
Captain / Total hours on type:
4900.00
Aircraft flight hours:
11098
Circumstances:
The airplane collided with frozen pack ice, three miles from the airport, during a GPS instrument approach. Instrument conditions of 3/4 mile visibility in snow and fog were reported at the time of the accident. The pilot stated that he began a steep descent with the autopilot engaged. He indicated that as the airplane crossed the final approach course, the autopilot turned the airplane inbound toward the airport. He continued the steep descent, noted the airplane had overshot the course, and the autopilot was not correcting very well. He disengaged the autopilot and manually increased the correction heading to intercept the final approach course. During the descent he completed the landing checklist, extended the landing gear and flaps, and was tuning both the communications and navigation radios. The pilot said he looked up from tuning the radios to see the sea ice coming up too quickly to react, and impacted terrain. The pilot relayed there were no pre accident anomalies with the airplane, and that he 'did not stay ahead of the airplane.'
Probable cause:
The pilot descended below the minimum descent altitude. Factors associated with this accident were the task overload of the pilot during the instrument approach, and not performing a level off.
Final Report: