Crash of a PZL-Mielec AN-2R near Volgograd

Date & Time: Jun 14, 1995
Type of aircraft:
Registration:
RA-68142
Flight Phase:
Survivors:
No
MSN:
1G195-47
YOM:
1982
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances near Volgograd. Occupant's fate unknown.

Crash of a Cessna F406 Caravan II in Nairobi

Date & Time: Jun 12, 1995
Type of aircraft:
Registration:
5Y-ING
Survivors:
Yes
MSN:
406-0024
YOM:
1988
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances at Nairobi-Wilson Airport. There were no casualties.

Crash of a De Havilland DHC-8-102 in Palmerston North: 4 killed

Date & Time: Jun 9, 1995 at 0925 LT
Operator:
Registration:
ZK-NEY
Survivors:
Yes
Schedule:
Auckland - Palmerston North
MSN:
055
YOM:
1986
Flight number:
AN703
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
7765
Captain / Total hours on type:
273.00
Copilot / Total flying hours:
6460
Copilot / Total hours on type:
341
Aircraft flight hours:
22154
Aircraft flight cycles:
24976
Circumstances:
At 08:17 Ansett New Zealand Flight 703 departed Auckland (AKL) as scheduled bound for Palmerston North (PMR). To the north of Palmerston North the pilots briefed themselves for a VOR/DME approach to runway 07 which was the approach they preferred. Subsequently Air Traffic Control specified the VOR/DME approach for runway 25, due to departing traffic, and the pilots re-briefed for that instrument approach. The IMC involved flying in and out of stratiform cloud, but continuous cloud prevailed during most of the approach. The aircraft was flown accurately to join the 14 nm DME arc and thence turned right and intercepted the final approach track of 250° M to the Palmerston North VOR. During the right turn, to intercept the inbound approach track, the aircraft’s power levers were retarded to 'flight idle' and shortly afterwards the first officer advised the captain ".... 12 DME looking for 4000 (feet)". The final approach track was intercepted at approximately 13 DME and 4700 feet, and the first officer advised Ohakea Control "Ansett 703" was "established inbound". Just prior to 12 miles DME the captain called "Gear down". The first officer asked him to repeat what he had said and then responded "OK selected and on profile, ten - sorry hang on 10 DME we’re looking for four thousand aren’t we so - a fraction low". The captain responded, "Check, and Flap 15". This was not acknowledged but the first officer said, "Actually no, we’re not, ten DME we’re..... (The captain whistled at this point) look at that". The captain had noticed that the right hand main gear had not locked down: "I don’t want that." and the first officer responded, "No, that’s not good is it, so she’s not locked, so Alternate Landing Gear...?" The captain acknowledged, "Alternate extension, you want to grab the QRH?" After the First Officer’s "Yes", the captain continued, "You want to whip through that one, see if we can get it out of the way before it’s too late." The captain then stated, "I’ll keep an eye on the airplane while you’re doing that." The first officer located the appropriate "Landing Gear Malfunction Alternate Gear Extension" checklist in Ansett New Zealand’s Quick Reference Handbook (QRH) and began reading it. He started with the first check on the list but the captain told him to skip through some checks. The first officer responded to this instruction and resumed reading and carrying out the necessary actions. It was the operator’s policy that all items on the QRH checklists be actioned, or proceeded through, as directed by the captain. The first officer started carrying out the checklist. The captain in between advised him to pull the Main Gear Release Handle. Then the GPWS’s audio alarm sounded. Almost five seconds later the aircraft collided with terrain. The Dash 8 collided with the upper slope of a low range of hills.
Probable cause:
The captain not ensuring the aircraft intercepted and maintained the approach profile during the conduct of the non-precision instrument approach, the captain's perseverance with his decision to get the undercarriage lowered without discontinuing the instrument approach, the captain's distraction from the primary task of flying the aircraft safely during the first officer's endeavours to correct an undercarriage malfunction, the first officer not executing a Quick Reference Handbook procedure in the correct sequence, and the shortness of the ground proximity warning system warning.
Final Report:

Ground explosion of a Douglas DC-9-32 in Atlanta

Date & Time: Jun 8, 1995 at 1908 LT
Type of aircraft:
Operator:
Registration:
N908VJ
Flight Phase:
Survivors:
Yes
Schedule:
Atlanta - Miami
MSN:
47321
YOM:
1969
Flight number:
VJA597
Crew on board:
5
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9500
Captain / Total hours on type:
3500.00
Copilot / Total flying hours:
3800
Copilot / Total hours on type:
552
Aircraft flight hours:
63000
Circumstances:
As ValuJet Flight 597 began its takeoff roll, a 'loud Bang' was heard by the occupants, the right engine fire warning light illuminated, the crew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain ordered evacuation of the airplane. A flight attendant (F/A) received serious puncture wounds from shrapnel and thermal injuries; another F/A and 5 passengers received minor injuries. Investigation revealed that an uncontained failure of the right engine had occurred due to fatigue failure of its 7th stage high compressor disc. The fatigue originated at a stress redistribution hole in the disc. Analysis of fatigue striation measurements indicated that the fatigue crack had originated before the disc was last overhauled at a repair station (Turk Hava Yollari) in 1991, but was not detected. Also, investigation of the repair station revealed evidence concerning a lack of adequate recordkeeping and a failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures.
Probable cause:
Failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disc, thus allowing the detectable crack to grow to a length at which the disc ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate record keeping system and the failure to use 'process sheets' to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.
Final Report:

Crash of a Fokker F28 Fellowship 1000 in Madang

Date & Time: May 31, 1995 at 2210 LT
Type of aircraft:
Operator:
Registration:
P2-ANB
Survivors:
Yes
Schedule:
Port Moresby – Lae – Madang
MSN:
11049
YOM:
1972
Flight number:
PX128
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Lae, the crew started the approach to Madang Airport runway 25. The visibility was limited by night and poor weather conditions. In heavy rain falls, the captain realized that all conditions were not met to land and decided to initiate a go-around. Following a short holding pattern, he started the approach to runway 07. The aircraft landed 300 metres past the runway threshold. On a wet runway surface, the aircraft was unable to stop within the remaining distance, overran and came to rest in a ravine. Due to torrential rain, all 39 occupants preferred to stay in the aircraft and were evacuated few dozen minutes later only. The aircraft was damaged beyond repair.
Probable cause:
The crew adopted a wrong approach configuration, causing the aircraft to land 300 metres past the runway threshold, reducing the landing distance available. The following contributing factors were reported:
- All conditions were not met for a safe landing,
- Wet runway surface,
- Poor braking action,
- Poor weather conditions,
- Limited visibility,
- Aquaplaning,
- Poor flight and approach planning.

Crash of a Piper PA-31-310 Navajo off Mbour: 6 killed

Date & Time: May 29, 1995
Type of aircraft:
Operator:
Registration:
6V-AGH
Survivors:
Yes
Schedule:
Dakar - Mbour
MSN:
31-205
YOM:
1968
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
Forty minutes into the flight from Dakar to Mbour, the crew informed ATC that an engine failed and was cleared to descent to 4,000 feet. Shortly later, the crew lost control of the airplane that crashed in shallow water about 500 metres off Mbour. Four passengers were rescued while six others occupants, including both pilots, were killed.
Probable cause:
Engine failure for unknown reasons. Nevertheless, it was also reported that the crew experience on this type of aircraft was limited.

Crash of an Embraer EMB-110P1 Bandeirante near Leeds: 12 killed

Date & Time: May 24, 1995 at 1751 LT
Operator:
Registration:
G-OEAA
Survivors:
No
Schedule:
Leeds - Aberdeen
MSN:
110-256
YOM:
1980
Flight number:
NE816
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
3257
Captain / Total hours on type:
1026.00
Copilot / Total flying hours:
302
Copilot / Total hours on type:
46
Aircraft flight hours:
15348
Circumstances:
On the morning of 24 May 1995 the aircraft had returned to its base at Leeds/Bradford from Aberdeen, U.K. on a scheduled passenger flight landing at 09:44 local time. The crew, which was not the one later involved in the accident, stated that all of the aircraft's systems and equipment had been serviceable during the flight. Some routine maintenance was performed on the aircraft which was later prepared for a scheduled passenger flight, NE816, to Aberdeen. It was positioned at the passenger terminal where it was taken over by the crew which was to operate the service, comprising the commander, who occupied the left hand seat, the first officer and a flight attendant. Nine passengers were boarded. The weather at Leeds/Bradford Airport was poor with Runway Visual Range (RVR) reported as 1,100 metres; scattered cloud at 400 feet above the aerodrome elevation of 682 feet and a light south-easterly wind. It was raining and the airfield had recently been affected by a thunderstorm. The freezing level was at 8,000 feet and warnings of strong winds and thunderstorms were in force for the Leeds/Bradford area. The crew called ATC for permission to start the engines at 17:41 hrs. Having backtracked the runway to line up, the aircraft took-off from runway 14 at 17:47 hrs and the crew was instructed by ATC to maintain the runway heading (143°M). The aircraft began to turn to the left shortly after becoming airborne. One minute and fifty seconds after the start of the take-off roll and as the aircraft was turning through a heading of 050° and climbing through 1,740 feet amsl, the first officer transmitted to Leeds/Bradford aerodrome control: "Knightway 816 we've got a problem with the artificial horizon sir and we'd like to come back." The aerodrome controller passed instructions for a radar heading of 360° and cleared the aircraft to 3,000 feet QNH. These instructions were read back correctly but the aircraft continued its left turn onto 300° before rolling into a right hand turn with about 30° of bank. About 20 seconds before this turn reversal, the aircraft had been instructed to call the Leeds/Bradford approach controller. The aircraft was now climbing through an altitude of 2,800 feet in a steep turn to the right and the approach controller transmitted: "I see you carrying out an orbit just tell me what i can do to help". The first officer replied: "Are we going straight at the moment sir" The controller informed him that the aircraft was at that time in a right hand turn but after observing further radar returns he said that it was then going straight on a south-easterly heading. The first officer's response to this transmission was: "Radar vectors slowly back to one four then sir please". The controller then ordered a right turn onto a heading of 340°. This instruction was correctly acknowledged by the first officer but the aircraft began a left hand turn with an initial angle of bank between 30° and 40°. This turn continued onto a heading of 360° when the first officer again asked "Are we going straight at the moment sir" to which the controller replied that the aircraft looked to be going straight. Seconds later the first officer asked: "Any report of the tops sir". This was the last recorded transmission from the aircraft, although at 17:52 hrs a brief carrier wave signal was recorded but it was obliterated by the controller's request to another departing aircraft to see if its pilot could help with information on the cloud tops. At this point, the aircraft had reached an altitude of 3,600 feet, having maintained a fairly constant rate of climb and airspeed. The ATC clearance to 3000 feet had not been amended. After the controller had confirmed that the aircraft appeared to be on a steady northerly heading, the aircraft immediately resumed its turn to the left and began to descend. The angle of bank increased to about 45° while the altitude reduced to 2,900 feet in about 25 seconds. As the aircraft passed a heading of 230° it ceased to appear on the secondary radar. There were four further primary radar returns before the aircraft finally disappeared from radar. There had been a recent thunderstorm in the area and it was raining intermittently with a cloud base of about 400 feet and a visibility of about 1,100 metres. Residents in the vicinity of the accident site reported dark and stormy conditions. Several witnesses described the engine noise as pulsating or surging and then fading just prior to impact. Other witnesses saw a fireball descending rapidly out of the low cloud base and one witness saw the aircraft in flames before it stuck the ground. All of the occupants died at impact. From subsequent examination it was apparent that, at a late stage in the descent, the aircraft had broken up, losing a large part of the right wing outboard of the engine, and the right horizontal stabiliser. There was some disruption of the fuselage before it struck the ground. The airborne structural failure that had occurred was the result of flight characteristics which were beyond the design limits of the aircraft following the loss of control shortly before impact.
Probable cause:
The following causal factors were identified:
- One or, possibly, both of the aircraft's artificial horizons malfunctioned and, in the absence of a standby horizon, for which there was no airworthiness requirement, there was no single instrument available for assured attitude reference or simple means of determining which flight instruments had failed.
- The commander, who was probably the handling pilot, was initially unable to control the aircraft's heading without his artificial horizon, and was eventually unable to retain control of the aircraft whilst flying in IMC by reference to other flight instruments.
- The aircraft went out of control whilst flying in turbulent instrument meteorological conditions and entered a spiral dive from which the pilot, who was likely to have become spatially disoriented, was unable to recover.
Final Report:

Crash of a Fokker F27 Friendship 600 in Jayapura

Date & Time: May 8, 1995
Type of aircraft:
Operator:
Registration:
PK-YPL
Survivors:
Yes
Schedule:
Wamena - Jayapura
MSN:
10435
YOM:
1970
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Wamena to Jayapura, the crew encountered technical problems with the hydraulic system that lost pressure. Following a normal approach, the aircraft landed at Jayapura-Sentani Airport. While rolling at a speed of about 60 knots, it deviated to the left, veered off runway and came to rest in a ravine. All 28 occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
It was determined that the brakes partially failed upon landing due to a loss of hydraulic pressure for unknown reasons. Nevertheless, the crew failed to use the auxiliary system that may help them to obtain more power.

Crash of a Piper PA-31-350 Navajo Chieftain in Sioux Lookout: 5 killed

Date & Time: May 1, 1995 at 1330 LT
Operator:
Registration:
C-GYPZ
Flight Phase:
Survivors:
No
Schedule:
Sioux Lookout - Red Lake
MSN:
31-7652168
YOM:
1976
Flight number:
SNY3101
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
1250
Captain / Total hours on type:
1000.00
Aircraft flight hours:
6784
Circumstances:
Bearskin flight 362, a Fairchild Swearingen Metro 23, departed Red Lake, Ontario, at 1300 central daylight saving time (CDT), with two pilots and one passenger on board, en route to Sioux Lookout on an instrument flight rules (IFR) flight plan. At approximately 30 nautical miles (nm) north of Sioux Lookout, the flight was cleared by the Winnipeg area control centre (ACC) for an approach to the Sioux Lookout airport. Air Sandy flight 3101, a Piper Navajo PA-31, departed Sioux Lookout at 1323 with one pilot and four passengers on board en route to Red Lake on a visual flight rules (VFR) flight. The pilot of Air Sandy 3101 reported clear of the Sioux Lookout control zone at 1326. No other communication was heard from the Air Sandy flight. At 1315 the Winnipeg ACC controller advised the Sioux Lookout Flight Service specialist that Bearskin 362 was inbound from Red Lake, estimating Sioux Lookout at 1332. At 1327, Bearskin 362 called Sioux Lookout Flight Service Station (FSS) and advised them they had been cleared for an approach and that they were cancelling IFR at 14 nm from the airport. At 1328, as Sioux Lookout FSS was giving an airport advisory to Bearskin 362, the specialist heard an emergency locator transmitter (ELT) emit a signal on the emergency frequencies. Moments later, the pilot of Bearskin 305, a Beechcraft B-99 in the vicinity of Sioux Lookout, advised the specialist that he had just seen a bright flare in the sky and that he was going to investigate. The pilot of Bearskin 305 stated that the flare had fallen to the ground and a fire was burning in a wooded area. A communications search was initiated to locate Bearskin 362, but the aircraft did not respond. A Search and Rescue aircraft from Trenton, Ontario, and an Ontario Ministry of Natural Resources (MNR) helicopter were dispatched to the site. The source of the fire was confirmed to be the Air Sandy aircraft. The MNR helicopter noticed debris and a fuel slick on a nearby lake, Lac Seul. It was later confirmed that Bearskin 362 had crashed into the lake. (See Appendix A.) The two aircraft collided in mid-air at 1328 during the hours of daylight at latitude 50º14'N and longitude 92º07'W, in visual meteorological conditions (VMC). All three persons on board the Bearskin aircraft and all five persons on board the Air Sandy aircraft were fatally injured.
Probable cause:
Neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Final Report:

Crash of a Swearingen SA227CC Metro 23 in Sioux Lookout: 3 killed

Date & Time: May 1, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
C-GYYB
Survivors:
No
Schedule:
Red Lake - Sioux Lookout
MSN:
CC-827B
YOM:
1993
Flight number:
BLS362
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
7330
Captain / Total hours on type:
580.00
Copilot / Total flying hours:
2810
Copilot / Total hours on type:
355
Aircraft flight hours:
3200
Circumstances:
Bearskin flight 362, a Fairchild Swearingen Metro 23, departed Red Lake, Ontario, at 1300 central daylight saving time (CDT), with two pilots and one passenger on board, en route to Sioux Lookout on an instrument flight rules (IFR) flight plan. At approximately 30 nautical miles (nm) north of Sioux Lookout, the flight was cleared by the Winnipeg area control centre (ACC) for an approach to the Sioux Lookout airport. Air Sandy flight 3101, a Piper Navajo PA-31, departed Sioux Lookout at 1323 with one pilot and four passengers on board en route to Red Lake on a visual flight rules (VFR) flight. The pilot of Air Sandy 3101 reported clear of the Sioux Lookout control zone at 1326. No other communication was heard from the Air Sandy flight. At 1315 the Winnipeg ACC controller advised the Sioux Lookout Flight Service specialist that Bearskin 362 was inbound from Red Lake, estimating Sioux Lookout at 1332. At 1327, Bearskin 362 called Sioux Lookout Flight Service Station (FSS) and advised them they had been cleared for an approach and that they were cancelling IFR at 14 nm from the airport. At 1328, as Sioux Lookout FSS was giving an airport advisory to Bearskin 362, the specialist heard an emergency locator transmitter (ELT) emit a signal on the emergency frequencies. Moments later, the pilot of Bearskin 305, a Beechcraft B-99 in the vicinity of Sioux Lookout, advised the specialist that he had just seen a bright flare in the sky and that he was going to investigate. The pilot of Bearskin 305 stated that the flare had fallen to the ground and a fire was burning in a wooded area. A communications search was initiated to locate Bearskin 362, but the aircraft did not respond. A Search and Rescue aircraft from Trenton, Ontario, and an Ontario Ministry of Natural Resources (MNR) helicopter were dispatched to the site. The source of the fire was confirmed to be the Air Sandy aircraft. The MNR helicopter noticed debris and a fuel slick on a nearby lake, Lac Seul. It was later confirmed that Bearskin 362 had crashed into the lake. (See Appendix A.) The two aircraft collided in mid-air at 1328 during the hours of daylight at latitude 50º14'N and longitude 92º07'W, in visual meteorological conditions (VMC). All three persons on board the Bearskin aircraft and all five persons on board the Air Sandy aircraft were fatally injured.
Probable cause:
Neither flight crew saw the other aircraft in time to avoid the collision. Contributing to the occurrence were the inherent limitations of the see-and-avoid concept which preclude the effective separation of aircraft with high closure rates, the fact that neither crew was directly alerted to the presence of the other aircraft by the Flight Service specialist or by onboard electronic equipment, and an apparent lack of pilot understanding of how to optimize avoidance manoeuvring.
Final Report: