Crash of a Grumman S-2E Tracker in Bahía Blanca

Date & Time: Nov 12, 1996
Type of aircraft:
Operator:
Registration:
0703/2-AS-24
Flight Type:
Survivors:
Yes
Schedule:
Bahía Blanca - Bahía Blanca
MSN:
325
YOM:
1957
Country:
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 Bahía Blanca-Comandante Espora Airbase. For unknown reasons, the aircraft landed on its belly and came to rest. Both pilots escaped uninjured.

Crash of a Cessna 340A in Richland: 2 killed

Date & Time: Jul 27, 1996 at 0855 LT
Type of aircraft:
Operator:
Registration:
N341TL
Flight Type:
Survivors:
No
Schedule:
Richland - Richland
MSN:
340A-1268
YOM:
1981
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4239
Captain / Total hours on type:
1240.00
Circumstances:
The pilot-under-instruction (PUI) who possessed an expired medical, and the pilot-in-command (PIC), an ATP pilot with 1240 hours in the Cessna 340, departed on the third training flight for the PUI in the aircraft. The second training flight, flown the previous Saturday, had included single-engine work. The aircraft was observed in the vicinity of the Richland airport by witnesses, several of whom reported the left propeller turning slowly. All witnesses reported seeing the aircraft descending rapidly to the ground in a nose down attitude and several witnesses described the descent as a spin. The aircraft impacted the ground in a near vertical, nose low attitude and was destroyed by fire. Postcrash examination of the aircraft revealed the left propeller in the feathered position and power signatures on the blades of the right propeller. Disassembly of both engines revealed no pre-impact mechanical malfunction. The gear and flaps were up and the rudder trim tab showed about 5 degrees of left tab trim. The information manual for the Cessna 340 indicates that the air minimum control speed (single engine), Vmca is 82 KIAS. The manual also indicates that a more suitable airspeed for one engine inoperative training events is 91 KIAS.
Probable cause:
The pilot-in-command's allowing the aircraft's airspeed to decrease below the single-engine minimum control speed (Vmc) resulting in a stall/spin condition. Factors contributing to the accident were the pilot-in-command's allowing the left engine to be shut down as well as his allowing the aircraft's airspeed to decelerate below the manufacturer's recommended intentional one-engine inoperative airspeed. A third factor was the aircraft's low altitude at the stall/spin entry which precluded a successful recovery.
Final Report:

Crash of a Beechcraft 200 Super King Air near Bouaflé: 3 killed

Date & Time: Jun 28, 1996 at 0900 LT
Operator:
Registration:
TU-TJE
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Yamoussoukro - Yamoussoukro
MSN:
BB-163
YOM:
1976
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was engaged in a local training flight at Yamoussoukro Airport. Following several circuits, the crew was cleared to descend from 3,000 to 1,000 feet for a new instrument approach. In limited visibility due to foggy conditions, the aircraft descended below de MDA then struck trees and crashed in a prairie located near Bouaflé, about 40 km northwest of Yamoussoukro Airport. All three pilots were killed.
Probable cause:
Controlled flight into terrain after the crew descended below MDA in poor visibility.

Crash of a Douglas DC-3A-S1C3G in Conroe

Date & Time: Jun 20, 1996 at 1408 LT
Type of aircraft:
Registration:
N23WT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Conroe - Conroe
MSN:
11650
YOM:
1943
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
16500
Captain / Total hours on type:
707.00
Aircraft flight hours:
51307
Circumstances:
During initial takeoff climb the copilot who was manipulating the controls called for METO (maximum except takeoff) power. After the pilot-in-command set METO power, the left engine lost power. The PIC took the controls from the copilot and called for him to feather the left propeller. The copilot did not hear the call to feather the left propeller. Maintaining an indicated airspeed of 90 knots and wings level attitude, the airplane descended into trees and impacted a rural residential paved street. The cockpit area and main fuselage were consumed by a post crash fire. Examination of the throttle quadrant revealed the propeller control levers were forward, the mixture control levers were autorich, the throttle for the right engine was forward, and the throttle for the left engine was at idle. According to a FAA operations inspector maintaining 90 knots with the propeller not feathered would result in the aircraft descending. The pilot and copilot had not completed a proficiency check or flight check for the DC3 type aircraft within the previous 24 months. Examination of the left engine did not disclose any preexisting anomalies.
Probable cause:
The flight instructor's failure to use the single engine best angle of climb airspeed resulting in a loss of control of the aircraft. Factors were the loss of power to the left engine for undetermined reasons, the flight instructor not being qualified to be pilot-in-command in the DC3, his lack of recent experience in the DC3, and the lack of suitable terrain for the forced landing.
Final Report:

Crash of a Boeing 727-286 in Rasht: 4 killed

Date & Time: Jun 9, 1996 at 1455 LT
Type of aircraft:
Operator:
Registration:
EP-IRU
Flight Type:
Survivors:
Yes
Schedule:
Rasht - Rasht
MSN:
21079
YOM:
1975
Location:
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew departed Tehran-Mehrabad Airport at 1233LT on a training flight to Rasht. Following 14 touch-and-go manoeuvres completed successfully, the crew approached the airport but forgot to lower the landing gear. The aircraft landed on its belly and slid on runway 09 for a period of 30 seconds and on a distance of 2,100 metres. Despite the situation, the crew decided to take off again and continued to climb when the rear fuselage caught fire. The crew declared an emergency, extended the undercarriage manually and was cleared to land on runway 09. On final approach, the aircraft became unstable, lost height and crashed in a field located 5 km short of runway. Four crew members were killed while three others were injured. The aircraft was destroyed. §
Probable cause:
The following findings were reported:
- The crew failed to follow the approach checklist,
- The crew forgot to lower the landing gear,
- Poor crew coordination,
- Lack of crew resources management,
- Wrong decision on part of the crew to take off following a belly landing,
- Following the belly landing, the aircraft suffered a fire and was not fit to fly.

Crash of a Learjet 25C in Ribeirão Preto: 2 killed

Date & Time: Jun 4, 1996 at 1320 LT
Type of aircraft:
Registration:
PT-KBC
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Uberaba – Ribeirão Preto
MSN:
25-165
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
250.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
420
Circumstances:
The crew departed São Paulo on a training flight to Ribeirão Preto with an intermediate stop in Uberaba. On approach to Ribeirão Preto-Leite Lopes Airport, the instructor decided to reduce power on the left engine to simulate a failure and to complete a touch-and-go manoeuvre. After touchdown, the left engine power lever remained in the idle position so the captain took over control and attempted to take off as he judged it impossible to stop on the remaining runway. The aircraft took off but landed back about 92 metres past the runway end. Out of control, it collided with a truck and a tree and came to rest, bursting into flames. A man in the truck as well as one pilot were killed while three other pilots were injured. The aircraft was destroyed.
Probable cause:
The following findings were reported:
- There are indications of the presence of psychological variables that may have influenced the instructor's decision to perform the touch-and-go manoeuvre.
- There was inadequate supervision, at the technical and operational level, by the aircraft operating company, due to the lack of training, inadequate instruction and absence of flight simulator training.
- There was an error made by the pilots due to the inadequate use of the crew resources in the cockpit intended for the operation of the aircraft, due to an ineffective fulfillment of the tasks assigned to each of the crew and the non-observance of the operational rules.
- Even though the crew was qualified for the type of flight, there was inadequate planning regarding the absence of a takeoff and landing briefing.
- There was an error made by the copilot, when the delay in reducing the power levers, as soon as the locking of the left engine lever was established during the dash on the ground, with an inadequate assessment of the situation in this regard.
- There was the participation of the training process received, due to quantitative and qualitative deficiency, which did not attribute to pilots the full technical conditions to be developed in the activity, regarding the lack of simulator training, lack of a company training program that included CRM and local flights, among others.
- There are indications that the difficulties reported by the pilots in relation to the throttle were caused by the rupture of fibers in the cable that transfers its control to the FCU. This cable slides inside a corrugated cover and can be jammed if any fiber in the cable breaks.
Final Report:

Crash of a Beechcraft T-44A Pegasus in the Gulf of Mexico: 3 killed

Date & Time: Mar 25, 1996
Type of aircraft:
Operator:
Registration:
160839
Flight Phase:
Flight Type:
Survivors:
No
MSN:
LL-1
YOM:
1977
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
Crashed in unknown circumstances in the Gulf of Mexico while completing a training mission. All three crew members, two pilots and an instructor, were killed.
Crew:
Cpt John Krafft,
1st Lt Ronald Pahl,
Ltjg Robert Roch.

Crash of a Vickers Viscount 808 in Belfast

Date & Time: Mar 24, 1996 at 2135 LT
Type of aircraft:
Operator:
Registration:
G-OPFE
Flight Type:
Survivors:
Yes
Schedule:
Belfast - Belfast
MSN:
291
YOM:
1958
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15601
Captain / Total hours on type:
3918.00
Circumstances:
The two crew members had reported at Stansted at 1130 hrs to catch a passenger flight to Belfast where they were rostered for a training detail; immediately prior to this duty day, they both had two days off. The first officer had completed a command course on the simulator the previous week and this training detail was part of his conversion to the left hand seat; the training captain had also been involved in the simulator the previous week. The detail was planned to involve two flights; the first would cover the mandatory items for the type rating test (1179) and the second would complete the first officer's base check and initial line check. On arrival at Belfast, the crew checked in to the airport hotel,changed into uniform and went to the meteorological office at approximately 1600 hrs for a weather briefing. This briefing indicated that the weather was close to the limits required for the completion of the type rating test items but, with a forecast of a suitable area to the north of the airfield, the crew decided to carry on with the detail. For the first flight, G-OPFE left the stand at 1815 hrs and took off at 1827 hrs. All the necessary items were completed successfully, albeit with some difficulty because of the variable cloud base, and the crew landed at 2010 hrs. By 2015 hrs, G-OPFE was back on stand and the crew kept the engines running while they had a short brief for the second flight. At 2025 hrs,they taxied off stand and positioned for a departure off Runway 07. On this second flight, following a take off at 2031 hrs, the training captain initiated an outboard engine failure just after VR by retarding the associated throttle. The appropriate remedial actions were simulated andthe first officer carried out a 3 engine ILS approach and go-around to Runway 17; there had been no abnormal switch positions required because of the simulated engine failure. The go-around was followed by a 3 engine VOR approach to landon Runway 07. The different runways were used because there is no ILS on Runway 07, the runway in use. After landing,the first officer repositioned G-OPFE and made a full power take-off from Runway 07, commencing his roll at the intersection with Runway 17. The aircraft was climbed to 4,000 feet amsl and established in the cruise at 200 kt IAS. During this cruise, there were no unserviceabilities noted with G-OPFE. The crew continued in a north-westerly direction until approximately 5 nm from Eglinton Airport when they requested, and were given, permission to turn back towards Belfast International Airport. For the subsequent approach, the surface wind was 090°/15 kt,visibility was 2,500 metres and the cloud was scattered at 1,000 feet and overcast at 4,200 feet agl. After establishing contact with Aldergrove radar, the crew were cleared to commence a VOR/DME approach to Runway 07 for afinal landing. It was confirmed from the CVR that the 'Initial Approach' checks were completed 'down to the line'. However,although the first officer at one stage commented that it was a bit early to complete the rest of the 'Initial Approach' checks,there was no evidence that these or the 'Finals' checks were subsequently requested or actioned. The landing gear would normally be selected down during the 'Initial Approach, below the line' checks and confirmed during the 'Finals' checks. The final approach profile was closely monitored by the commander and, from comments on the CVR, the approach appeared very stable. In the later stages of approach, the first officer was heard asking for 85% flap andthe training captain was heard confirming this selection. These were the only comments heard referring to flap selection or position,although it is acceptable company practice for crews to request flap changes by visual means. The final flap position (100%)is used to decrease ground roll and is selected during the flare or after touchdown. Other relevant comments which were heardon the CVR included a reference to landing lights; this is the last item on the "Finals" checks. As the throttles were retarded in the flare, the gear warning horn was heard on the CVR, followed within 23 seconds by sounds of the propellers contacting the runway surface. After coming to a stop on the runway, the crew secured and evacuated the aircraft. The airport Rescue and Fire Fighting Service were on the scene inless than one minute.
Probable cause:
Subsequent runway and aircraft examination showed that G-OPFE had made a gentle touchdown on Runway 07 close to the PAPI position, somewhat left of the centreline. Initial contact wason both inboard propeller tips. After a few metres, both outboard propellers contacted the runway, progressively followed by radio aerials mounted beneath the fuselage, the fuselage undersurface, the inboard part of both inboard flaps and the No 3 engine nacelle. The aircraft continued down the left side of the runway,across the intersecting Runway 17/35, and came to rest on Runway 07 after a ground slide of approximately 480 metres. Damage consisted of severe bending and scraping of all propeller blades, abrasion of much of the undersurface of the fuselage and the No 3 engine nacelle lower cowl, and abrasion and moderate distortion of the inboard flaps A very small quantity of fuel was reportedly released from the No 3 engine nacelle. There was no fire. Examination showed that the flaps had been in the fully deployed position (100%, 47°) at touchdown and the flap lever was found selected at 47°. All three landing gear legs had been fully retracted at touchdown and throughout the ground slide. After the aircraft had been lifted, the three legs deployed into downlock without difficulty using the emergency lowering procedure. The landing gear selector was found with the 'Down' button pushed in, but the electric actuator that is switched by the selector was found in the fully up position; this actuator had not been disturbed during recovery operations. The landing gear indicator was found in the 'Day' (ie bright) setting. Examination and testing of relevant systems was carried out, except for the hydraulic generation system; this indicated that the landing gear operating and indication systems functioned normally.
Final Report:

Crash of a Fletcher FU-24-954 at Nakhon Ratchasima AFB: 2 killed

Date & Time: Mar 4, 1996
Type of aircraft:
Operator:
Registration:
604
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Nakhon Ratchasima - Nakhon Ratchasima
MSN:
289
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew was completing a local training mission at Nakhon Ratchasima AFB. After takeoff, in unknown circumstances, the single engine aircraft crashed in Nong Phai Lom, near the airport. Both pilots were killed.

Crash of a Cessna 208 Caravan I in Bulwer

Date & Time: Feb 24, 1996 at 0743 LT
Type of aircraft:
Operator:
Registration:
3010
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
MSN:
208-0160
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft departed Margate Airport to take part to a combined exercice. En route, while cruising in limited visibility, the crew encountered technical problems with the engine and decided to attempt an emergency landing. The aircraft clipped trees and crashed near Bulwer. All 11 occupants escaped uninjured. The passengers were attached to the 41st Squadron.