Crash of a Cessna 208 Caravan I off Green Island

Date & Time: Feb 8, 2004 at 1610 LT
Type of aircraft:
Operator:
Registration:
VH-CYC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Cairns - Cairns
MSN:
208-0108
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5333
Captain / Total hours on type:
211.00
Circumstances:
The aircraft, with two pilots on board, was being operated for pilot type endorsement training. Air Traffic Control (ATC) had cleared the pilots to conduct upper level air work between 4,000 and 5,000 ft above mean sea level (AMSL) within a 5 NM radius of Green Island, Queensland. Following the upper level air work, the crew requested, and were granted a clearance for, a simulated engine failure and descent to 2,000 ft. The pilot in command (PIC) reported that while completing the simulated engine failure training, he had retarded the power lever to the FLIGHT IDLE stop and the fuel condition lever to the LOW IDLE range, setting a value of 55% engine gas generator speed (Ng). The pilot under training then set the glide attitude at the best glide speed (for the operating weight) of about 79 knots indicated airspeed (KIAS). The PIC then instructed the pilot under training to place the propeller into the feathered position, and maintain best glide speed. The PIC reported that he instructed the pilot under training to advance the emergency power lever (EPL) to simulate manual introduction of fuel to the engine. According to the PIC, he then noticed that there was no engine torque increase, with the engine inter-turbine temperature (ITT or T5) and Ng rapidly decreasing, and a strong smell of fuel in the cockpit. While the pilot under training flew the aircraft, the PIC placed the ignition switch to the ON position and also selected START on the engine starter switch. He then reportedly placed the EPL to the CLOSED position, the propeller to the UNFEATHERED position and the fuel condition lever to the IDLE CUTOFF position to clear the excess fuel from the engine. The PIC reported that they then increased the aircraft airspeed to 120 KIAS, at which point he reintroduced fuel into the engine by advancing the fuel condition lever. He reported that following these actions, the strong fuel smell persisted. As the aircraft approached 1,500 ft, the PIC broadcast a MAYDAY, informing ATC that they had a 'flameout' of the engine and that they were going to complete a forced landing water ditching near Green Island. While the pilot under training flew the aircraft, the PIC placed the propeller into the feathered position, closed the fuel condition lever to the IDLE CUTOFF position and turned off the starter and ignition switches. They then completed a successful landing in a depth of about 2 m of water near Green Island. The pilots evacuated the aircraft without injury. The aircraft, which sustained minor damage during the ditching, but subsequent substantial damage due to salt water immersion, was recovered to the mainland. Following examination of all connections and control linkages, the engine was removed for examination under the supervision of the Australian Transport Safety Bureau (ATSB) at the engine manufacturer's overhaul facility. The engine trend monitoring (ETM) data logger was also removed from the aircraft for examination.
Probable cause:
The following factors were identified:
1. The pilots of CYC were conducting in-flight familiarization training using the emergency power lever. That procedure was not contained in the aircraft manufacturer's pilot operating handbook.
2. The engine manufacturer's documentation contained information on the use of the emergency power lever, which did not preclude the use of the emergency power lever for in-flight familiarization training.
3. The engine sustained a flameout at an altitude above mean sea level from which reignition of the engine was not successfully completed.
4. Erosion of the first-stage compressor blades would have reduced the aerodynamic efficiency of the compressor blades.
Final Report:

Crash of a Piper PA-61 Aerostar (Ted Smith 601) off Byron Bay: 2 killed

Date & Time: Jan 27, 2004 at 1335 LT
Operator:
Registration:
VH-WRF
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Coolangatta - Coolangatta
MSN:
61-0497-128
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7127
Captain / Total hours on type:
308.00
Copilot / Total flying hours:
283
Copilot / Total hours on type:
3
Circumstances:
The Ted Smith Aerostar 601 aircraft, registered VH-WRF, departed Coolangatta at 1301 ESuT with a flight instructor and a commercial pilot on board. The aircraft was being operated on a dual training flight in the Byron Bay area, approximately 55 km south-south-east of Coolangatta. The aircraft was operating outside controlled airspace and was not being monitored by air traffic control. The weather in the area was fine with a south-easterly wind at 10 - 12 kts, with scattered cloud in the area with a base of between 2,000 and 2,500 ft. The purpose of the flight was to introduce the commercial pilot, who was undertaking initial multi-engine training, to asymmetric flight. At approximately 1445, the operator advised Australian Search and Rescue that the aircraft had not returned to Coolangatta, and that it was overdue. Recorded radar information by Airservices Australia revealed that the aircraft had disappeared from radar coverage at 1335. Its position at that time was approximately 18 km east-south-east of Cape Byron. Search vessels later recovered items that were identified as being from the aircraft in the vicinity of the last recorded position of the aircraft. Those items included aircraft checklist pages, a blanket, a seat cushion from the cabin, as well as a number of small pieces of cabin insulation material. No item showed any evidence of heat or fire damage. No further trace of the aircraft was found.
Probable cause:
Without the aircraft wreckage or more detailed information regarding the behaviour of the aircraft in the final stages of the flight, there was insufficient information available to allow any conclusion to be drawn about the development of the accident. Many possible explanations exist. The fact that no radio transmission was received from the aircraft around the time radar contact was lost could indicate that the aircraft was involved in a sudden or unexpected event at that time that prevented the crew from operating the radio. The speed regime of the aircraft during the last recorded data points indicated that airframe failure due to aerodynamic overload was unlikely. The nature of the items from the aircraft that were recovered from the ocean surface indicated that the aircraft cabin had been ruptured during the accident sequence.
Final Report:

Crash of a Cessna 441 Conquest in Greenacres City: 1 killed

Date & Time: Dec 30, 2003 at 1115 LT
Type of aircraft:
Operator:
Registration:
N111RC
Flight Type:
Survivors:
No
Schedule:
Boca Raton – West Palm Beach
MSN:
441-0188
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5832
Aircraft flight hours:
4036
Circumstances:
The airplane, flown by an airline transport pilot, departed in day visual meteorological conditions for an 18-nautical mile flight from the home base airport to another airport where the pilot planned to conduct a practice instrument approach. The pilot contacted approach control and requested a practice ILS approach. The controller instructed the pilot to proceed northwest bound and maintain 2,500 feet msl. Radar indicated the airplane tracked a northerly heading instead of a northwesterly heading as instructed. The airplane continued on a northerly heading until 1113:48 when it was about 5 miles southwest of the destination airport at 1,900 feet msl with a ground speed of 172 knots. At this point, the controller instructed the pilot to turn southbound and remain clear of Class C airspace. Radar coverage for the next 50 seconds was intermittent. At 1114:29, radar picked up the airplane about 4 miles southwest of the destination airport at 1,800 feet msl, a ground speed of 106 knots, and a heading of 101 degrees. The airplane continued heading east-southeast for about 30 seconds and its ground speed continued to decay. At 1114:58, it entered an abrupt descent, going from 1700 feet to 200 feet in 15 seconds. The last radar return was recorded at 1115:13 and showed the airplane at 200 feet msl, a ground speed of 64 knots, and a heading of 093 degrees. Several witnesses observed the airplane descend in a "flat spin" and impact a shallow canal in a residential area. Examination of the accident site revealed that the airplane impacted the canal in a nearly flat and level attitude. No evidence of any pre-impact mechanical discrepancies with the airframe or engines was found that would have prevented normal operation. Testing of the electronic engine controls revealed that both units were functional, but under some conditions would trip to manual mode. Further investigation determined that the units tripping to manual mode was due to an electrical overstress that failed the same thermistor within each unit. The reason for the electrical overstress or when it occurred could not be determined; however, it is probable it occurred at impact when the units were submerged in water. Even if the units tripped to manual mode in flight, this would only result in the loss of the torque and temperature limiting and propeller synchrophaser systems, meaning the pilot would have to manually adjust the power levers as required to maintain the proper torque and exhaust gas temperature. Post accident toxicology testing of the pilot's blood revealed chlorpheniramine, an over-the-counter sedating antihistamine, at more than ten times higher than the level expected with a typical maximum over-the-counter dose. It is probable that the pilot's performance and judgment were substantially impaired by his very high blood level of chlorpheniramine.
Probable cause:
The pilot's failure to maintain aircraft control, which resulted in an inadvertent stall/spin and subsequent uncontrolled descent into a canal. A factor was the pilot's impairment by the drug
chlorpheniramine.
Final Report:

Crash of a Cessna 550 Citation II in Mineral Wells

Date & Time: Nov 18, 2003 at 1410 LT
Type of aircraft:
Operator:
Registration:
N418MA
Flight Type:
Survivors:
Yes
Schedule:
Fort Worth – Mineral Wells
MSN:
550-0144
YOM:
1980
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16500
Captain / Total hours on type:
500.00
Circumstances:
A designated pilot examiner (DPE) was administering a type-rating check ride from the jump seat (located behind co-pilot's seat), and instructed the second-in-command (SIC) (required for the check ride and occupying the front right seat) to reduce the power on one engine to simulate a single engine approach. Approximately 23 seconds later, the airplane began to "drop rapidly." To arrest the descent, both pilots simultaneously applied full power on both engines, and the applicant (occupying the front left seat) increased the airplane's pitch attitude to 12 degrees. However, the airplane continued to descend and touched down short of the landing threshold for the runway. A post-impact fire consumed the airplane. According to the applicant, after takeoff, he demonstrated several maneuvers, and was then provided vectors for a VOR instrument approach. While executing the approach, it was "really bumpy", and they hit a gust of wind, which resulted in him having to correct the airplane's attitude back to straight and level flight. When the airplane was approximately one mile from the end of the runway, he looked outside and saw that he was high on the approach and extended the flaps to 40 degrees. Shortly after, the PIC reduced power on the left engine to simulate a single-engine approach. When the airplane was approximately 1/4 to 1/2-mile from the end of the runway, at 400 feet mean sea level (msl) (about 366 feet above ground level), Vref 110, the airplane began to sink rapidly, and it impacted the ground. The applicant said that he, "never experienced wind shear like that before...and in hindsight it would have been more helpful if they had a better understanding of the wind conditions before they tried to land." Under current FAA regulations, even though the pilot in the right seat (the applicant's flight instructor) acted as the SIC for the purpose of the check ride, the applicant was not type rated in the airplane, and technically, could not be designated as the pilot-in-command (PIC). The instructor was type rated in the airplane; and therefore, was the PIC.
Probable cause:
The pilot-in-command's failure to maintain control of the airplane while executing a simulated engine failure on final approach. A factor was the windshear.
Final Report:

Crash of a Grumman G-64 Albatross in Fort Pierce: 2 killed

Date & Time: Sep 25, 2003 at 1126 LT
Type of aircraft:
Registration:
N70258
Flight Type:
Survivors:
Yes
Schedule:
Fort Pierce - Fort Pierce
MSN:
G-418
YOM:
1955
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
13000
Captain / Total hours on type:
450.00
Copilot / Total flying hours:
12800
Aircraft flight hours:
4276
Circumstances:
According to the pilot, during climb-out from runway 09 at an altitude of approximately 500 feet the right engine warning red magnetic chip detector light illuminated. The pilot decided to shut down the right engine and return to the airport. Shortly after making that decision the left engine began to lose power. The airplane was unable to maintain altitude, and the pilot prepared to make an off-airport emergency landing in a field. The airplane collided with the trees as the pilot maneuvered for the emergency landing. Examination of the airframe, and flight controls revealed no anomalies. Examination of the left and right engine revealed no mechanical anomalies. Examination of cockpit fuel selector controls revealed that the left engine fuel selector handle was in the off position and the right engine fuel selector handle was set in the left tank position. During the in-flight engine secure procedures the pilot is required to place the inoperative engine fuel selector in the off position.
Probable cause:
A loss of engine power due to the pilot placing the fuel selector in the off position which resulted in fuel starvation to the left engine, after the pilot intentionally shut down the right engine.
Final Report:

Crash of a BAe 125-700A near Beaumont: 3 killed

Date & Time: Sep 20, 2003 at 1854 LT
Type of aircraft:
Operator:
Registration:
N45BP
Flight Type:
Survivors:
No
Schedule:
Houston - Beaumont
MSN:
257026
YOM:
1978
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
5230
Captain / Total hours on type:
3521.00
Copilot / Total flying hours:
3817
Copilot / Total hours on type:
2684
Aircraft flight hours:
9781
Aircraft flight cycles:
7098
Circumstances:
The purpose of the flight was for the instructor-pilot to prepare the first and second pilots for their FAA Part 135 competency and proficiency checks scheduled to be conducted in the accident airplane the following week, with operator proving tests to follow shortly thereafter. The first pilot obtained a computer science corporation (CSC) direct user access terminal service (DUATS) weather briefing and filed an instrument flight rules (IFR) flight plan. The instructor-pilot was listed as the pilot-in-command. The airplane took off and proceeded to its designated practice area. According to the cockpit voice recorder (CVR), the pilots practiced various maneuvers under the direction of the instructor-pilot, including steep turns and approaches to stalls. Then the first pilot was asked the to demonstrate an approach-to-landing stall. The first pilot asked the instructor-pilot if he had "ever done stalls in the airplane?" The instructor-pilot replied, "It's been awhile." The first pilot remarked, "This is the first time I've probably done stalls in a jet. Nah, I take that back, I've done them in a (Lear)." The instructor pilot said he had stalled "the JetStar on a [FAR] one thirty five ride." Flaps were extended and the landing gear was lowered. Digital electronic engine control (DEEC) recorded a power reduction that remained at idle. According to national track analysis program (NTAP) data, the stall was initiated from an altitude of 5,000 feet. The stick shaker sounded and shortly thereafter, the recording ended. The consensus of 25 witness' observations was that the airplane was flying at low altitude and doing "erratic maneuvers." One witness said it "seemed to stop in midair," then pitched nose down. Some witnesses said that the airplane was spinning. Other witnesses said it was in a flat spin. Still another witness said the airplane fell "like a falling leaf." The airplane impacted marshy terrain in a nose-down, wings-level attitude. Wreckage examination revealed the landing gear was down and the flaps were set to 25 degrees. Both engines' compressor/turbine section blades were gouged and bent in the opposite direction of rotation, and there were rotational scoring marks on both cases. No discrepancies were noted.
Probable cause:
The first pilot's failure to maintain aircraft control and adequate airspeed. Contributing factors included performing intentional stalls at too low an altitude to afford a safe recovery, the pilot's failure to add power in an attempt to recover, and the flight instructor's inadequate supervision of the flight.
Final Report:

Crash of a PZL-Mielec AN-2R in Trollhättan

Date & Time: Aug 26, 2003 at 1730 LT
Type of aircraft:
Registration:
LY-KAE
Flight Type:
Survivors:
Yes
Schedule:
Trollhättan - Trollhättan
MSN:
1G196-54
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Trollhättan-Målöga Airport, the aircraft nosed over and came to rest upside down. Both occupants escaped uninjured while the aircraft was damaged. It was apparently repaired.
Probable cause:
The pilot used excessive brakes after touchdown, causing the brakes to block. The landing maneuver was completed with a tailwind component.

Crash of a Piper PA-31-310 Navajo in Clearwater: 2 killed

Date & Time: Aug 21, 2003 at 1648 LT
Type of aircraft:
Registration:
N93DC
Flight Type:
Survivors:
Yes
Site:
Schedule:
Saint Augustine - Clearwater
MSN:
31-7712017
YOM:
1977
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
760
Copilot / Total flying hours:
600
Aircraft flight hours:
6019
Circumstances:
The airplane experienced an in-flight loss of control and crashed into a residential area. The flight departed VFR and when near the destination airport flew between areas with VIP Level 5 reflectivity. There was no record of a preflight weather briefing. The flight continued towards the destination airport and encountered lesser intensity reflectivity. An individual at the destination airport reported hearing an occupant of the airplane ask, "...for an advisory for the field", and "...what the weather was like." The individual at the airport advised that the winds appeared to be in favor for runway 16, which was left hand traffic, the runway was wet, and the rain seemed to be letting up. There were no further communications from the accident aircraft. A pilot-rated witness located north of the destination airport, and nearly due west of the accident site reported seeing the airplane on what he thought was final approach to runway 16, but the airplane was "very low." The witness reported the airplane made a, "sudden, sharp turn to the left [flying eastbound]." He then lost sight of the airplane and proceeded to the accident site. Another pilot-rated witness who was located in a vehicle approximately 1/4 mile west-northwest of the accident site reported observing an airplane flying from the northwest. The airplane banked to the left flying eastbound at a, "...very slow airspeed and banking and yawing left and right." While flying eastbound it appeared to him that whomever was flying the airplane was executing a go-around as evidenced by the landing gear retracting, followed by the flaps. The airplane then appeared to climb which appeared very unstable, again yawing left and right. The airplane then banked to the right, stalled, and entered a spin impacting the ground. Still another witness who was located approximately 1/10th of a nautical mile east-southeast from the accident site reported he came out of his house after the rain ended and was facing west. He saw the accident airplane from the northwest and thought it had descended lower than normal. The airplane was flying above the tops of nearby trees and while flying in a southeasterly direction, pitched up, "darn near got 90 degrees", rolled to the left, and descended straight down. He reported that he did not hear the engines, and thought he should have been able to hear them if the pilot had "revved them up." He estimated his view of the flight lasted approximately 10-15 seconds, and couldn't tell if the landing gear was extended. He did not see any smoke trailing the airplane, and after the impact he ran into his house, called 911, got into his car, and drove to the scene. He heard an explosion, and saw flames. He got to the airplane and helped rescue a passenger who was beating on the aircraft's door. The airplane descended nearly vertical in a residential area and damaged trees approximately 30 feet above ground level. A post crash fire consumed the cockpit, cabin, portions of both wings, and portions of both engines. Examination of the flight controls, both engines, propellers, and propeller governors revealed no evidence of preimpact mechanical failure or malfunction. Accessories of both engines including the magnetos were destroyed by the post crash fire. Additionally, both servo fuel injectors were heat damaged which precluded bench testing. During disassembly of the right servo fuel injector, the hub stud was found separated from the hub at the fuel diaphragm. No determination was made whether this occurred during disassembly or occurred preimpact. No determination could be made as to who was operating the controls at the time of the accident.
Probable cause:
The failure of the flightcrew to maintain airspeed (Vs) resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with the ground.
Final Report:

Crash of a Beechcraft T-1A Jayhawk in Biloxi

Date & Time: Aug 16, 2003 at 2221 LT
Type of aircraft:
Operator:
Registration:
91-0093
Flight Type:
Survivors:
Yes
Schedule:
Del Rio - Biloxi
MSN:
TT-34
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Mishap Student pilot (MSP) was flying an Instrument Landing System (ILS) approach to runway 21 at Keesler AFB. They were in Visual Meteorological Conditions (VMC) at night and the runway was wet. After some deviations on the approach, they arrived over the threshold on a normal glide slope and faster (about 114 kts) than the computed approach speed of 108 kts. The aircraft touched down approximately 1500 feet down the runway. The Mishap Instructor Pilot (MIP) actuated the speed brakes/spoilers switch and the student began to immediately apply brake pressure. After 4-5 seconds, the instructor recognized that the aircraft was not decelerating and declared that she was taking control of the aircraft. The instructor immediately applied maximum braking with no perceived deceleration. She then grabbed the glare shield in an attempt to gain additional leverage on the brakes and again felt no perceived deceleration. At this point, the aircraft was rapidly running out of available runway. The instructor selected the emergency brakes just prior to arriving at the departure end threshold and the brakes locked resulting in a hydroplane skid. The aircraft departed the prepared surface and came to a halt 190 feet later. As a result of the runway departure, the right main and nose gear collapsed, and the forward fuselage and both wings were heavily damaged.
Probable cause:
Based on clear and convincing evidence, the Board President determined that this mishap was caused by a combination of several factors during the landing sequence. First, the Mishap Student Pilot (MSP) flew faster than the computed approach and landing speeds. Additionally she maintained higher than idle thrust for the first few seconds after touchdown. Because of these factors, the aircraft did not settle completely on the runway after touchdown-as the struts were not completely compressed. This put the aircraft systems in the "AIR" mode meaning that the speed brakes/spoilers could not deploy. Finally, the runway was wet; and the crew was inexperienced and thus did not recognize the anti-skid cycling at high speeds on the wet runway.

Crash of a Lockheed C-130H Hercules at Boufarik AFB: 15 killed

Date & Time: Jun 30, 2003 at 1100 LT
Type of aircraft:
Operator:
Registration:
7T-WHQ
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Boufarik AFB - Boufarik AFB
MSN:
4926
YOM:
1982
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
The crew departed Boufarik AFB on a local training flight. Shortly after takeoff, while in initial climb, the crew informed ATC about an engine fire and elected to return for an emergency landing. Few seconds later, control was lost and the aircraft crashed in the district of Beni Mered, less than 2 km from the end of runway 22. The aircraft was totally destroyed by impact forces and a post crash fire as well as eight houses. All four crew members were killed as well as 11 people on the ground. Six other people on the ground were seriously injured.
Probable cause:
Engine fire for unknown reasons.