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.

Crash of a Rockwell Shrike Commander 500S in Manatí: 3 killed

Date & Time: Feb 11, 1996 at 1638 LT
Registration:
N79NU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
San Juan - San Juan
MSN:
500-3206
YOM:
1974
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
6560
Captain / Total hours on type:
50.00
Aircraft flight hours:
3323
Circumstances:
The flight was a dual instruction flight for the purpose of giving the dual student an orientation to the aircraft. Witnesses observed the aircraft flying from east to west at a slow speed. The right wing dropped and then returned to level. The right wing and nose dropped and the aircraft descended in a 45-60 degree nose down attitude. As the aircraft descended the wings rolled back and forth and something was observed moving on the outboard right wing area. The aircraft did not recover from the descent and crashed nose first at a slow speed into a swamp area. Post crash examination of the aircraft showed no evidence to indicate pre-crash mechanical malfunction or failure of the aircraft structure, flight controls, engines, propellers, or systems. The rudder trim was found in the neutral position and the elevator trim was found set for 70% of the aircraft nose up trim. Toxicology tests showed the dual student had .319 ug/ml of marihuana in urine, .010 ug/ml marijuana in blood, and 10.90 ug/ml of acetaminophen in blood. The pilot-in-command/flight instructor had 47.90 ug/ml acetaminophen and 89.20 ug/ml salicylate in urine. The pilot-in-command had hand injuries consistent with operating the aircraft's controls at the time of the accident. The dual student did not have hand injuries consistent with operation of the aircraft's controls.
Probable cause:
Failure of the flight crew, for undetermined reasons, to recover from a stall and resulting uncontrolled descent. This resulted in the aircraft colliding with the terrain while in a 45-60 degree nose down attitude at a slow speed.
Final Report:

Crash of a Cessna 425 Conquest I in Hanover: 1 killed

Date & Time: Jan 24, 1996
Type of aircraft:
Operator:
Registration:
D-IBAA
Flight Type:
Survivors:
Yes
Schedule:
Hanover - Hanover
MSN:
425-0163
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew (one instructor and one student pilot) were completing a local training flight at Hanover-Langenhagen Airport. On final approach, the instructor shut down an engine to simulate a failure. The pilot-in-command lost control of the aircraft that stalled and crashed in a field short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and both occupants were seriously injured. Few hours later, the pilot under supervision died from his injuries.

Crash of a Piper PA-31-350 Navajo Chieftain in San Jose: 2 killed

Date & Time: Dec 23, 1995 at 0019 LT
Operator:
Registration:
N27954
Flight Type:
Survivors:
No
Site:
Schedule:
Oakland - San Jose
MSN:
31-7952062
YOM:
1979
Flight number:
AMF041
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4659
Captain / Total hours on type:
914.00
Aircraft flight hours:
9840
Aircraft flight cycles:
10966
Circumstances:
The aircraft impacted mountainous terrain in controlled flight during hours of darkness and marginal VFR conditions. The flight was being vectored for an instrument approach during the pilot's 14 CFR Part 135 instrument competency check flight. The flight was instructed by approach control to maintain VFR conditions, and was assigned a heading and altitude to fly which caused the aircraft to fly into another airspace sector below the minimum vectoring altitude (MVA). FAA Order 7110.65, Section 5-6-1, requires that if a VFR aircraft is assigned both a heading and altitude simultaneously, the altitude must be at or above the MVA. The controller did not issue a safety alert, and in an interview, said he was not concerned when the flight approached an area of higher minimum vectoring altitudes (MVA's) because the flight was VFR and 'pilots fly VFR below the MVA every day.' At the time of the accident, the controller was working six arrival sectors and experienced a surge of arriving aircraft. The approach control facility supervisor was monitoring the controller and did not detect and correct the vector below the MVA.
Probable cause:
The failure of the air traffic controller to comply with instructions contained in the Air Traffic Control Handbook, FAA Order 7110.65, which resulted in the flight being vectored at an altitude below the minimum vectoring altitude (MVA) and failure to issue a safety advisory. In addition, the controller's supervisor monitoring the controller's actions failed to detect and correct the vector below the MVA. A factor in the accident was the flightcrew's failure to maintain situational awareness of nearby terrain and failure to challenge the controller's instructions.
Final Report:

Crash of a Rockwell Shrike Commander 500S in Horn Island: 1 killed

Date & Time: Dec 12, 1995 at 0918 LT
Operator:
Registration:
VH-UJP
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Horn Island - Horn Island
MSN:
500-3074
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
11740
Captain / Total hours on type:
119.00
Circumstances:
At approximately 0910 EST, the aircraft took off from runway 32 at Horn Island and commenced a normal climb. Shortly after, it adopted a nose-high attitude and commenced a wingover type manoeuvre to the right. Witnesses described the aircraft as being in a nose-low attitude, and at a height of approximately 600 ft to 700 ft above ground level after the completion of this manoeuvre. It then abruptly adopted a level attitude and rapidly entered a spin to the left. Witnesses on the ground reported that at approximately the same time as the aircraft entered the spin, engine power became asymmetric, with the right engine continuing to deliver considerable power. The aircraft continued to descend in a fully developed flat spin, with no observed signs of an attempt to recover. The impact was heard shortly after the aircraft descended behind vegetation to the north-west of the aerodrome. The accident was reported to Flight Service by radio at 0918. The wreckage was located on a beach approximately 2 km to the north-west of the aerodrome. The aircraft was destroyed by impact forces and the pilot sustained fatal injuries.
Probable cause:
The following findings were reported:
1. The pilot held a valid pilot licence and medical certificate.
2. The pilot was endorsed on the aircraft type.
3. The aircraft entered a flat spin to the left with no reported signs of an attempt to recover.
4. The aircraft struck the ground whilst established in a flat left spin.
5. The right engine was producing considerable power prior to impact.
6. Indications were that the left engine was producing little or no power. Its propeller was in the feathered position prior to impact.
7. No evidence was found to indicate a malfunction or pre-existing defect with the aircraft or its systems which may have affected normal operation during this flight.
8. No evidence was found to indicate pilot incapacitation as the result of a medical condition or the presence of alcohol or drugs.
9. The pilot's behaviour on the morning of the accident was not consistent with what was generally accepted to be a thorough and professional attitude to aviation.
Final Report:

Crash of a Beechcraft D18S in Fort Collins

Date & Time: Nov 30, 1995 at 1330 LT
Type of aircraft:
Operator:
Registration:
N8603A
Flight Type:
Survivors:
Yes
Schedule:
Fort Collins - Fort Collins
MSN:
A-557
YOM:
1951
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
800.00
Circumstances:
The pilot-owner/operator, who was seated in the right seat, said the left seat pilot made the approach to runway 15. The wind was reported as being from the southwest at 20 knots with no reference to gusts. He said the pilot aligned the airplane 40 feet left of runway centerline and failed to flare. The airplane contacted the runway, bounced back into the air with the right wing high, and began drifting to the left. The right seat pilot took control, first trying to lower the wing then attempting to abort the landing. The airplane struck the ground and cartwheeled. The left seat pilot said he was 'receiving training' from the pilot-owner and was 'not at the controls' at the time of the accident.
Probable cause:
The second pilot's failure to compensate for wind conditions and his improper recovery from a bounced landing, and the pilot-in-command's inadequate supervision of the flight. Factors were the second pilot's lack of landing experience in the airplane make/model, and the gusty crosswind conditions.
Final Report:

Crash of an Antonov AN-24B in Shymkent

Date & Time: Nov 1, 1995
Type of aircraft:
Operator:
Registration:
UN-47710
Flight Type:
Survivors:
Yes
Schedule:
Shymkent - Shymkent
MSN:
6 99 004 05
YOM:
1966
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Shymkent Airport. On approach, at an altitude of about 300 metres, the instructor shut down one engine to simulate a failure. The pilot-in-command requested full power on the remaining engine but the flight engineer misinterpreted the instruction and shut down the second engine. The aircraft lost speed and height and struck the ground with a positive acceleration of 2,6 g before coming to rest in a field 1,100 metres short of runway threshold. All four occupants were injured and the aircraft was damaged beyond repair.
Probable cause:
Loss of control on final approach due to lack of crew coordination during an engine failure simulation.

Crash of a Morane-Saulnier M.S.760B Paris II in Uzech: 4 killed

Date & Time: Oct 11, 1995
Operator:
Registration:
117
Flight Phase:
Flight Type:
Survivors:
No
MSN:
117
YOM:
1962
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
While in a training flight, the aircraft went out of control and crashed in a field located in Uzech, about 15 km north of Cahors, Lot. The aircraft was destroyed and all four occupants were killed.
Crew:
Cpt Jean-Marie Bachelot,
Cpt Henri-Claude Johary.
Passengers:
Michel Magnier,
Jacqueline Spirkovitch.
Probable cause:
It was reported that an engine failed in flight and caught fire for unknown reasons.

Crash of a Swearingen SA227AC Metro III in Tamworth: 2 killed

Date & Time: Sep 16, 1995 at 1957 LT
Type of aircraft:
Operator:
Registration:
VH-NEJ
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Tamworth - Tamworth
MSN:
AC-629B
YOM:
1985
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4132
Captain / Total hours on type:
1393.00
Copilot / Total flying hours:
1317
Copilot / Total hours on type:
1
Aircraft flight hours:
15105
Circumstances:
Two company pilots were undergoing first officer Metro III type-conversion flying training. Both had completed Metro III ground school training during the week before the accident. A company check-and-training pilot was to conduct the type conversions. This was his first duty period after 2 weeks leave. Before commencing leave, he had discussed the training with the chief pilot. This discussion concerned the general requirements for a co-pilot conversion course compared to a command pilot course but did not address specific sequences or techniques. The three pilots met at the airport at about 1530 EST on 16 September 1995. During the next 2 hours and 30 minutes approximately, the check-and-training pilot instructed the trainees in daily and pre-flight inspections, emergency equipment and procedures, and cockpit procedures and drills (including the actions to be completed in the event of an engine failure), as they related to the aircraft type. The briefing did not include detailed discussion of aircraft handling following engine failure on takeoff. The group began a meal break at 1800 and returned to the aircraft at about 1830 to begin the flying exercise. The check-and-training pilot was pilot in command for the flight and occupied the left cockpit seat. One trainee occupied the right (co-pilot) cockpit seat while the other probably occupied the front row passenger seat on the left side. This person had the use of a set of head-phones to listen to cockpit talk and radio calls. The aircraft departed Tamworth at 1852, some 40 minutes after last light. Witnesses described the night as very dark, with no moon. Under these conditions, the Tamworth city lighting, which extended to the east from about 2 km beyond the end of runway 12, was the only significant visual feature in the area. The co-pilot performed the takeoff, his first in the Metro III. For about the next 30 minutes, he completed various aircraft handling exercises including climbing, descending, turning (including steep turns), and engine handling. No asymmetric flight exercises were conducted. The check-and-training pilot then talked the co-pilot through an ILS approach to runway 30R with an overshoot and landing on runway 12L. The landing time was 1940. The aircraft had functioned normally throughout the flight. After clearing the runway, the aircraft held on a taxiway for 6 minutes, with engines running. During this period, the crew discussed the next flight which was to be flown by the same co-pilot. The check-and-training pilot stated that he was going to give the co-pilot a V1 cut. The co-pilot objected and then questioned the legality of night V1 cuts. The check-and-training pilot replied that the procedure was now legal because the company operations manual had been changed. The co-pilot made a further objection. The check-and-training pilot then said that they would continue for a Tamworth runway 30R VOR/DME approach and asked the co-pilot to brief him on this approach. The crew discussed the approach and the check-and-training pilot then requested taxi clearance. The aircraft was subsequently cleared to operate within a 15-NM radius of Tamworth below 5,000 ft. The crew then briefed for the runway 12L VOR/DME approach. The plan was to reconfigure the aircraft for normal two-engine operations after the V1 cut and then complete the approach. The crew completed the after-start checks, the taxi checks, and then the pre-take-off checks. The checks included the co-pilot calling for one-quarter flap and the check-and-training pilot responding that one-quarter flap had been selected. The crew briefed the take-off speeds as V1 = 100 kts, VR = 102 kts, V2 = 109 kts, and Vyse = 125 kts for the aircraft weight of 5,600 kg. Take-off torque was calculated as 88% and watermethanol injection was not required. The aircraft commenced the take-off roll at 1957.05. About 25 seconds after brakes release, the check-and-training pilot called 'V1', and less than 1 second later, 'rotate'. The aircraft became airborne at 1957.32. One second later, the check-and-training pilot reminded the co-pilot that the aircraft attitude should be 'just 10 degrees nose up'. After a further 3 seconds, the check-and-training pilot retarded the left engine power lever to the flight-idle position. Over the next 4 seconds, the recorded magnetic heading of the aircraft changed from 119 degrees to 129 degrees. The co-pilot and then the check-and-training pilot called that a positive rate of climb was indicated and the landing gear was selected up 15 seconds after the aircraft became airborne. The landing gear warning horn began to sound at approximately the same time. After 19 seconds airborne, and again after 30 seconds, the check-and-training pilot reminded the co-pilot to hold V2. Three seconds later, the check-and-training pilot said that the aircraft was descending. The landing gear warning horn ceased about 1 second later. By this time, the aircraft had gradually yawed left from heading 129 degrees, through the runway heading of 121 degrees, to 107 degrees. After being airborne for 35 seconds, the aircraft struck a tree approximately 350 m beyond, and 210 m left of, the upwind end of runway 12L. It then rolled rapidly left, severed power lines and struck other trees before colliding with the ground in an inverted attitude and sliding about 70 m. From the control tower, the aerodrome controller saw the aircraft become airborne. As it passed abeam the tower, the controller directed his attention away from the runway. A short time later, all lighting in the tower and on the airport failed and the controller noticed flames from an area to the north-east of the runway 30 threshold. Within about 30 seconds, when the emergency power supply had come on line, the controller attempted to establish radio contact with the aircraft. When no response was received, he initiated call-out of the emergency services.
Probable cause:
The following factors were reported:
1. There was no enabling legislative authority for AIP (OPS) para. 77.
2. CASA oversight, with respect to the company operations manual and specific guidance concerning night asymmetric operations, was inadequate.
3. The company decided to conduct V1 cuts at night during type-conversion training.
4. The check-and-training pilot was assigned a task for which he did not possess adequate experience, knowledge, or skills.
5. The check-and-training pilot gave the co-pilot a night V1 cut, a task which was inappropriate for the co-pilot's level of experience.
6. The performance of the aircraft during the flight was adversely affected by the period the landing gear remained extended after the simulated engine failure was initiated and by the control inputs of the co-pilot.
7. The check-and-training pilot did not recognise that the V1 cut exercise should be terminated and that he should take control of the aircraft.
Final Report:

Crash of a De Havilland DHC-4A Caribou off Labuan: 3 killed

Date & Time: Jul 31, 1995 at 1244 LT
Type of aircraft:
Operator:
Registration:
M21-13
Flight Type:
Survivors:
Yes
Schedule:
Labuan - Labuan
MSN:
281
YOM:
1969
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew was completing a local training flight at Labuan Airport. Following several touch-and-go manoeuvres, the crew initiated a new approach when one of the engine failed. The aircraft stalled and crashed in the sea few hundred metres offshore. Three crew members were killed and three others were seriously injured.
Probable cause:
Engine failure on approach for unknown reasons.