Crash of a Let L-410UVP-E9 in Arusha

Date & Time: Jul 26, 1999 at 1610 LT
Type of aircraft:
Operator:
Registration:
5H-PAB
Flight Type:
Survivors:
Yes
Schedule:
Arusha - Arusha
MSN:
96 27 15
YOM:
1996
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12000
Captain / Total hours on type:
700.00
Circumstances:
The aircraft took off from Arusha Airport (ARK) at 12:35 hours for a circuit training. It was carrying one instructor, a pilot trainee and three passengers. The aircraft was flying VFR. The instructor said that he intended to execute nine touch and go circuit operations, three of which were to be performed with 42° flaps, another three with 18° flaps and the rest with zero degree flaps. The first six circuits were performed uneventfully. Before initiating the first flapless landing the instructor ordered the trainee to extend his approach and establish a six-mile final to runway 09. When the aircraft was established on the final for runway 09 the instructor saw that the aircraft was a bit too low and ordered the trainee to adjust his approach. After 5H-PAB was established on the approach slope the instructor advised the trainee to call when he needed props fully forward (setting propellers into full coarse pitch). This he subsequently did and the instructor, aware of the relatively high aircraft speed for the configuration advised the trainee to be careful on the flare in order to avoid the possibility of the tail skid hitting the ground. When the aircraft was flared, the tail skid hit and scraped the ground followed by the belly and the nose underside section. After sliding for 164 metres the aircraft came to rest on the runway with the engines still running. The instructor carried out the emergency shut down checks and evacuated the aircraft. It was only after touchdown that the crew realised that they had belly landed. The commander then proceeded to select reverse thrust. There was no fire and none of the occupants was injured. The instructor said that he had forgotten to lower the landing gear because of his preoccupation with the rate of descent and the execution of the flapless flare. The pilot under instruction testified that he had concentrated too much an the technical side of flying to the point of forgetting to call for the gear down selection. There was only one checklist in use in the cockpit which was contained in a book and this was being used by the instructor. The instructor testified to have used the checklist for the first six landings. The checklist was not used for the accident landing. None pilot of the pilots reported to have heard the landing gear horn.
Probable cause:
Failure of the crew to follow the approach checklist and to lower the landing gear.

Crash of a Britten-Norman BN-2T Islander AL1 at RAF Middle Wallop

Date & Time: Jun 30, 1999
Type of aircraft:
Operator:
Registration:
ZG994
Flight Type:
Survivors:
Yes
Schedule:
Middle Wallop - Middle Wallop
MSN:
2206
YOM:
1989
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at RAF Middle Wallop. After landing, the twin engine failed to stopped, overran and came to rest. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Crash of a De Havilland DHC-4 Caribou in Kuching: 5 killed

Date & Time: May 24, 1999 at 1315 LT
Type of aircraft:
Operator:
Registration:
M21-05
Flight Type:
Survivors:
No
Schedule:
Kuching - Kuching
MSN:
270
YOM:
1969
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew was completing a local training flight at Kuching Airport. On final approach, one of the engine failed. The aircraft lost height and crashed in a swampy area near the airport. All five occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Boeing 737-247 in Loma Bonita

Date & Time: May 10, 1999
Type of aircraft:
Operator:
Registration:
B-12001
Flight Type:
Survivors:
Yes
Schedule:
Loma Bonita - Loma Bonita
MSN:
20127
YOM:
1969
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Loma Bonita Airport which has a 1,400 metres long 18/36 runway. After touchdown, the crew initiated the braking procedure but the aircraft was unable to stop within the remaining distance. It overran, rolled for about 100 metres then came to rest. All six occupants escaped uninjured. A fire erupted and destroyed the aircraft in few minutes as local firebombers were not sufficiently trained and well equipped.
Probable cause:
It was determined that following a wrong approach configuration, the crew landed too far down the runway, reducing the landing distance available. Brake marks were found on the last portion of the runway.

Crash of a Learjet 24D in Ribeirao Preto: 5 killed

Date & Time: Apr 7, 1999 at 1147 LT
Type of aircraft:
Registration:
PT-LEM
Flight Type:
Survivors:
No
Schedule:
São Paulo - Ribeirão Preto
MSN:
24-270
YOM:
1973
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
4000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
6000
Copilot / Total hours on type:
100
Circumstances:
The aircraft departed São Paulo-Congonhas on a training flight to Ribeirão Preto-Leite Lopes Airport, carrying five crew members, instructor and pilots. On final approach to runway 18, during the last segment, just prior to touchdown, the aircraft rolled to the right, causing the right wing tip to struck the runway surface. The pilot-in-command overcorrected, the aircraft went out of control and crashed 420 metres past the first impact, bursting into flames. All five occupants were killed.
Probable cause:
Contributing Factors:
- There was the participation of individual psychological variables in the pilot-in-command's performance due to the excess of self-confidence and self-demand in his customary behavior, besides the dissimulation regarding his real qualification for the type of flight. The personality with traces of permissiveness and insecurity of the co-pilot also contributed to the occurrence, as it allowed the aircraft to be operated by an unqualified pilot, with no employment link with the company.
- There was a lack of adequate supervision by Manacá Táxi Aéreo, as it allowed a crew member who had not operated the type of aircraft for one year and had not made any type of flight for four months, besides not having any employment relationship with that company. It is also necessary to consider the failure of supervision at the organizational level due to the issue of an incorrect license by the DAC, giving rise to the possibility of its use for the revalidation of license in aircraft for which the pilot was not qualified to exercise the function of commander.
- The entire sequence of events began with pilot errors resulting from the pilot's lack of flight experience in the left-hand seat on the aircraft in question.
- The inadequate use of cockpit resources destined to the aircraft operation, due to an ineffective accomplishment of the tasks assigned to each crew member, besides the interpersonal conflict resulting from the co-pilot's intervention in the pilot in command operation, in the final approach phase, already close to the aircraft's touchdown, configure the collaboration of this factor to the accident.
- The inadequate use of the aircraft commands, by the pilot in command, making excessive aileron corrections in the final approach phase, near the landing.
- The pilot was qualified as a co-pilot on the equipment, but due to a typing error, he was issued a pilot license. Thus, the situation and operation of the pilot in question were totally irregular.
Final Report:

Crash of a Grumman G-21A Goose in Fort Lauderdale: 1 killed

Date & Time: Mar 25, 1999 at 1139 LT
Type of aircraft:
Registration:
N5548A
Flight Type:
Survivors:
Yes
Schedule:
Watson Island - Fort Lauderdale
MSN:
1150
YOM:
1942
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
10000
Captain / Total hours on type:
520.00
Aircraft flight hours:
13136
Circumstances:
The pilot was receiving a competency flight in the seaplane from an FAA inspector. The pilot was returning to their initial departure airport, descended to 1,000 feet, contacted the control tower for landing instructions, and was instructed to enter on a right base. Before he could acknowledge the landing instructions the engines started to make loud, rough, and unusual noises. The pilot informed the control tower that he was 2 miles south , declared an emergency, and stated he had a bad engine on the left side. The FAA inspector stated the pilot started the emergency procedure, the manifold pressure and rpm was fluctuating. The inspector could not determine the dead engine by the dead foot, dead engine method, because her rudder pedals were stowed. She pointed out a pasture and the pilot stated they were going to the water. She did not recall the pilot shutting down the engine or feathering the propeller. She could not recall the final seconds of the flight. The airplane collided with a tree, canal bank, and came to rest inverted in the canal. Examination of the airframe and flight control systems revealed no evidence of a precrash mechanical failure or malfunction. Examination of the left propeller revealed it was not feathered. The No. 6 front forward spark plug ignition lead was disconnected from the spark plug. The ignition lead shroud threaded coupling on the No. 4 front forward spark plug was unscrewed and the carbon wire was exposed. The left and right engines were removed from the airplane and transported to an authorized FAA approved repair station. The left engine was placed in an engine test cell. The engine was started, developed rated power, and achieved takeoff power. The spark plug lead was removed from the No.6 forward cylinder. The left magneto had a 125 rpm drop during the magneto check. The right magneto had a 75 rpm drop. The magneto drop exceeded the allowable drop indicated by the engine overhaul manual. The right engine was placed in a engine test cell. The engine was started, developed rated power, and achieved takeoff power. Review of the FAA inspectors FAA Form 4040.6 revealed she was not Event Based Current (EBC) for the 4th quarter of the Flight Standards EBC program, and she did not meet the EBC quarterly events required by the end of the 14-day grace period. FAA Order 4040.9 states for an FAA inspector to be eligible / assigned to perform flight certification job function they must be EBC current., and inspectors should not accept assignments without being in compliance with the FAA Order. Managers and supervisors should not assign inspectors who are not current. The FAA inspector's supervisor was aware that the inspector was not current. He contacted the FAA Safety Regulation Branch, FAA Southern Region Headquarters, and stated that FAA Southern Region indicated that the inspector could administer the checkride. FAA Southern Region stated at no time did they approve or agree to an operation outside the parameters of the FAR's, Inspector Handbook or FAA Order.
Probable cause:
The pilots failure to correctly identify an in-flight emergency (fluctuating manifold pressure and rpm due to a disconnected spark plug lead / unscrewed ignition lead shroud) and failure to complete the engine shutdown procedure once it was initiated (propeller not feathered). This resulted in a forced landing and subsequent in-flight collision with a tree, dirt bank and canal. Contributing to the accident was the FAA inspectors improper supervision of the pilot, and the improper supervision of the inspector by her supervisor, in his failure to follow written procedures / directives in assigning a non-current inspector to conduct a competency flight.
Final Report:

Crash of a Cessna 402B off Pahokee: 3 killed

Date & Time: Dec 8, 1998 at 1902 LT
Type of aircraft:
Operator:
Registration:
N788SP
Flight Type:
Survivors:
No
Schedule:
Fort Lauderdale - Pahokee
MSN:
402B-1312
YOM:
1978
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1440
Captain / Total hours on type:
8.00
Aircraft flight hours:
7940
Circumstances:
The flight departed Fort Lauderdale's Executive Airport (FXE) at about 1833 on a northwesterly heading for the co-located Pahokee VOR/airport (PHK) on the second training session of the day for the 2 front seat occupants. This particular flight had a dual purpose, in that the left seat occupant/new-hire was getting a 'pre-check ride' by the right seat occupant/instructor/PIC, and the instructor was being observed by the air taxi's director of operations in anticipation of an endorsement for an FAA designation as a company check airman. The flight was not in contact with any ATC facility and was squawking a transponder code consistent with non-controlled, VMC flight. At 1902, the Miami ARTCC lost radar contact at the 334 degree radial/12 nmi from the PHK VOR at 1,300 feet agl. Eight days later, the wreckage with its 3 occupants still inside, was located and recovered from the lake bottom. The location roughly corresponds with the radial of the PHK VOR that would have to be tracked while performing the VOR Runway 17 approach. The wreckage was intact except for 2 nacelle doors, the nose cone, and the left propeller, and revealed no engine, airframe, or component failure or malfunction. There was no evidence of a bird strike. Evidence revealed that both engines were developing power and the airplane was wings level in the approach configuration and attitude at water contact.
Probable cause:
The pilot's failure to maintain adequate altitude during the approach.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 100 in Antofagasta

Date & Time: Aug 19, 1998
Operator:
Registration:
935
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Antofagasta - Antofagasta
MSN:
7
YOM:
1966
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Antofagasta-Cerro Moreno Airport (Andrés Sabella Gálvez Intl Airport). At liftoff, the pilot-in-command initiated a sharp turn to the right, causing the left wing tip to struck the ground. Out of control, the aircraft crashed by the runway. All three occupants were injured and the aircraft was damaged beyond repair. It was reported that the pilot-in-command was a Mirage fighter jet captain. When ATC requested the crew to expedite the takeoff, the pilot-in-command made a sharp turn at low height, apparently not aware about the aircraft wingspan.

Crash of a Convair CV-240-17 in Aguadilla

Date & Time: Jun 1, 1998
Type of aircraft:
Registration:
N87949
Flight Type:
Survivors:
Yes
Schedule:
Aguadilla - Aguadilla
MSN:
202
YOM:
1950
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Aguadilla-Rafael Hernández Airport. Following several touch-and-go manoeuvres, the crew was approaching the airport when he inadvertently raised the landing gear prior to landing. The aircraft belly landed and came to rest. All three crew members escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Belly landing after the crew mistakenly raised the landing gear.

Crash of a Piper PA-31T Cheyenne I in Great Falls: 2 killed

Date & Time: May 19, 1998 at 1536 LT
Type of aircraft:
Registration:
N121BE
Flight Type:
Survivors:
No
Schedule:
Great Falls - Great Falls
MSN:
31-8004036
YOM:
1980
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2347
Aircraft flight hours:
2226
Circumstances:
The flight was on a practice nondirectional beacon (NDB) approach to Great Falls runway 34 in visual conditions. Abeam the final approach fix, the aircraft was 4 miles right of course. Upon being advised of this by ATC, the pilot corrected back to final with a 60-degree intercept angle, rolling out on course 3 miles from the runway. When the pilot called missed approach, the local controller (a trainee) instructed the pilot to make a 360-degree right turn to enter right downwind for runway 3, and the pilot acknowledged. The controller trainee then amended this instruction to a 180-degree right turn to enter right downwind for runway 21, then to a 180- degree right turn to enter right downwind for runway 3. The crew did not acknowledge the amended instruction. Controllers then observed the airplane had crashed. Witnesses reported the airplane entered a steep descent from a right turn and impacted the ground at a steep angle. The flight was described as recurrent training required by the owner's insurance; however, the second aircraft occupant's airline transport pilot and flight instructor certificates had been revoked, and he held only a private pilot certificate. Investigators found no evidence of aircraft malfunctions.
Probable cause:
The flight crew's failure to maintain aircraft control.
Final Report: