Crash of a Travel Air 4000 in Fort Myers

Date & Time: Nov 14, 2009 at 1018 LT
Type of aircraft:
Registration:
N3823
Flight Type:
Survivors:
Yes
Schedule:
Fort Myers - Fort Myers
MSN:
306
YOM:
1927
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
1789
Captain / Total hours on type:
60.00
Aircraft flight hours:
5284
Circumstances:
During approach, the pilot of the tailwheel-equipped biplane flew along at 20-30 feet above the runway until he was at midfield. The biplane touched down, bounced back in to the air, touched down again, and bounced once more prior to touching down for a third time in a nose-high attitude. The biplane then veered to the right, the right wing dipped, and the biplane cartwheeled, coming to rest inverted. The pilot had 60 hours of flight experience in the biplane. The previous owner had advised the pilot that landing the biplane took patience to land it perfectly and that attempting to land the biplane on asphalt with low experience could cause the biplane to bump repeatedly. He also advised that if the pilot pulled back on the control stick too soon during landing it could result in ballooning and porpoising.
Probable cause:
The pilot's improper recovery from a bounced landing and failure to maintain directional control, which resulted in a ground loop. Contributing to the accident was the pilot's minimal experience in the airplane make and model.
Final Report:

Crash of an ATR72-212 in Mumbai

Date & Time: Nov 10, 2009 at 1640 LT
Type of aircraft:
Operator:
Registration:
VT-KAC
Survivors:
Yes
Schedule:
Bhavnagar - Mumbai
MSN:
729
YOM:
2006
Flight number:
IT4124
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7160
Captain / Total hours on type:
2241.00
Copilot / Total flying hours:
973
Copilot / Total hours on type:
613
Aircraft flight hours:
9318
Circumstances:
As per the NOTAM, Runway 14/32 was under permanent maintenance on every Tuesdays since 10/11/2009 runway 27 was available only after runway intersection as runway 27A. To carry out operations on this reduced runway 27 a NOTAM ‘G’ No. G 0128/08 was issued by AAI on the same day of accident i.e. 10-11-2009 and designated as runway 27A for visual approach only. As per the NOTAM Landing Distance Available (LDA)/take off Distance available (TODA) was 1703 m. The weather conditions prevailing at the time of accident was winds 070/07 knots visibility 2800 m with feeble rain. Prior to Kingfisher aircraft, Air India aircraft IC-164, Airbus 319 had landed and reported to ATC that it had aquaplaned and broken two runway edge lights. The ATC acknowledged it and sent runway inspection vehicle to inspect the runway. The ATC person was not familiar with the terminology of ‘aquaplaning’ and not realizing the seriousness of it, cleared kingfisher aircraft for landing. At the time of accident there were water patches on the runway. ATC also did not transmit to the Kingfisher aircraft the information regarding aquaplaning reported by the previous aircraft. The DFDR readout revealed that kingfisher aircraft was not on profile as per localizer procedure laid down in NOTAM ‘G’ and was high and fast. The aircraft landed late on the runway and the runway length available was around 1000 m from the touchdown point. In the prevailing weather conditions this runway length was just sufficient to stop the aircraft on the runway. During landing the kingfisher aircraft aquaplaned and did not decelerate even though reversers and full manual braking was applied by both the cockpit crew. The aircraft started skidding toward the left of center line. On nearing the runway end, the pilot initiated a 45 ° right turn, after crossing ‘N 10’ Taxi track, the aircraft rolled into unpaved wet area. Aircraft rolled over drainage pipes & finally came to a stop near open drain. There was no fire. All the passenger safely deplaned after the accident.
Probable cause:
The accident occurred due to an unstabilized approach and decision of crew not to carry out a ‘Go-around’.
Contributory Factors:
i) Water patches on the runway 27
ii) Inability of the ATCO to communicate the aircraft about aquaplaning of the previous aircraft
iii) Lack of input from the copilot.
Final Report:

Crash of a Beechcraft B200 Super King Air in Greenville

Date & Time: Nov 9, 2009 at 1009 LT
Operator:
Registration:
N337MT
Flight Type:
Survivors:
Yes
Schedule:
Greenville - Greenville
MSN:
BB-1628
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15717
Aircraft flight hours:
3060
Circumstances:
The pilot flew the airplane to a maintenance facility and turned it in for a phase inspection. The next morning, he arrived at the airport and planned a local flight to evaluate some avionics issues. He performed a preflight inspection and then went inside the maintenance facility to wait for two avionic technicians to arrive. In the meantime, two employees of the maintenance facility test ran the engines on the accident airplane for about 30 to 35 minutes in preparation for the phase inspection. The pilot reported that he was unaware that the engine run had been performed when he returned to the airplane for the local flight. He referred to the flight management system (FMS) fuel totalizer, and not the aircraft fuel gauges, when he returned to the airplane for the flight. He believed that the mechanics who ran the engines did not power up the FMS, which would have activated the fuel totalizer, thus creating a discrepancy between the totalizer and the airplane fuel gauges. The mechanics who performed the engine run reported that each tank contained 200 pounds of fuel at the conclusion of the engine run. The B200 Pilot’s Operating Handbook directed pilots not take off if the fuel quantity gauges indicate in the yellow arc or indicate less than 265 pounds of fuel in each main tank system. While on final approach, about 23 minutes into the flight, the right engine lost power, followed by the left. The pilot attempted to glide to the runway with the landing gear and flaps retracted, however the airplane crashed short of the runway. Only residual fuel was found in the main and auxiliary fuel tanks during the inspection of the wreckage. The tanks were not breached and there was no evidence of fuel leakage at the accident site.
Probable cause:
A loss of engine power due to fuel exhaustion as a result of the pilot’s failure to visually verify that sufficient fuel was on board prior to flight.
Final Report:

Crash of a Beechcraft 1900D in Nairobi: 2 killed

Date & Time: Nov 9, 2009 at 0517 LT
Type of aircraft:
Operator:
Registration:
5Y-VVQ
Flight Type:
Survivors:
No
Schedule:
Nairobi – Guriceel
MSN:
UE-250
YOM:
1996
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Aircraft flight hours:
15866
Aircraft flight cycles:
15941
Circumstances:
The airplane departed Wilson Airport at 03:39 hours, transporting a cargo of miraa to Guriceel Airstrip, Somalia. Taxi, take off and climb were uneventful. However, at 04:23 and flying at FL230 the crew contacted Nairobi Area Control Centre (ACC) and requested for a turn back to Wilson Airport due to a 'slight problem'. At about the same time, the aircraft made a right turn from a heading of 50° to 240° magnetic and commenced descent. The crew reported descending to FL220 and expressed intention to descend further to FL180. However, ACC informed the crew to initially maintain FL200 due to traffic moving in the opposite direction. At 04:28 the crew informed ACC that they were unable to maintain FL200 and requested to descend to FL180 having crossed the opposite traffic. At 04:29, the crew confirmed to Air Traffic Control (ATC) that they were heading to Wilson Airport and indicated that they did not require any assistance. The aircraft continued descending until FL120. The Nairobi Approach Radar established contact with the aircraft at 04:41 and indicated to the crew that they were 98 nautical miles North East of November Victor. The crew was then told to turn left to a heading of 225° and report when they were top of descent, which they did. The crew reported again that they had a 'slight problem' and as a safety measure they had to shut down one engine. They also expressed desire to route direct to Silos. At 04:42 5Y-VVQ aligned with the North East access lane via Ndula Marker. At 04:45, the crew confirmed to Nairobi Approach Radar that the malfunction was on the left engine and again acknowledged that they did not require any assistance. At 04:51, the crew requested for radar vectors for an ILS approach to runway 06 at Jomo Kenyatta International Airport with a long final to runway 32 of Wilson Airport. At 05:09, the aircraft descended to 8000ft heading 260°. At 05:14, the crew was given vectors for runway 32 Wilson Airport. At the same time, the aircraft turned right to a heading 310° as it continued to descend to 7000ft. The crew confirmed the vectors and at 05:15 stated that they were passing Visual Meteorological Conditions (VMC). They were also informed that the Wilson Airport runway 32 was 6.5 nautical miles away in the two o'clock direction. The aircraft continued to descend to 6000ft and at 05:16, the crew confirmed sight of runway 32. The crew was then transferred from the radar to the Wilson Tower frequency for landing. 5Y-VVQ was cleared for a straight-in approach to runway 32. Wilson Tower then communicated to the crew airfield QNH was 1022hPa and that winds were calm. The Tower controller had 5Y-VVQ visual and it was cleared to land on runway 32. At about the same time, the aircraft made a 5° right bank and again leveled off before making a steep left bank rising to 30° within 4 seconds. According to Tower and eyewitness information, the aircraft appeared high on approach and on short-final, it was observed to turn a bit to the right. This was followed by a steep left bank. The aircraft left wing hit the ground first approximately 100 meters outside the airport perimeter fence. The aircraft then flipped over, hitting and breaking the airport fence and coming to rest on the left of runway 32 approximately 100 meters from its threshold. The aircraft immediately caught fire upon the impact. Upon further investigations and interview of company personnel, it was established that the crew had made the decision to shut down the left engine following a low oil pressure warning. The flight crew did not declare an emergency.
Probable cause:
The investigation determined the probable cause of the accident as loss of aircraft control at low altitude occasioned by operation of the aircraft below VMCA during one engine inoperative approach.
Other significant contributory factors to this accident include:
- Inadequate pilot training on single engine operation and VMCA;
- inappropriate handling technique during one engine inoperative flight;
- inability of the pilot to monitor the degrading airspeed.

Crash of a Tupolev TU-142MZ in the Tatar Strait: 11 killed

Date & Time: Nov 6, 2009 at 2119 LT
Type of aircraft:
Operator:
Registration:
55 red
Flight Type:
Survivors:
No
Schedule:
Mongokhto AFB - Mongokhto AFB
MSN:
0 60 41 75
YOM:
1990
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
Following a training flight over the Okhotsk Sea, the four engine was returning to its base at Mongokhto AFB. While descending by night, the aircraft crashed in the Tatar Strait between the Island of Sakhalin and the Sikhote-Alin region. Some debris were found about 15 km off Sadinga Cape. All 11 occupants were killed.

Crash of a Learjet C-21A at Talil AFB

Date & Time: Nov 2, 2009 at 1430 LT
Type of aircraft:
Operator:
Registration:
84-0094
Flight Type:
Survivors:
Yes
MSN:
35-540
YOM:
1985
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a positioning flight to Talil AFB (Imam Ali), Iraq. On approach, the aircraft was too high and descended with an excessive speed and a tailwind component of 10 knots. The crew failed to initiate a go-around and the aircraft landed about two-third down the runway. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest in a sandy area about 60 metres past the runway end. Both pilots escaped uninjured while the aircraft was damaged beyond repair and later destroyed by soldiers from the 68th Transportation Company.
Probable cause:
The accident investigation board (AIB) president found clear and convincing evidence that the mishap crew failed to sufficiently reduce speed and altitude during their approach to execute a normal landing, failed to complete the appropriate checklist for a high speed partial flap landing, and failed to recognize that there was insufficient runway remaining to safely land. Finally, the mishap crew failed to initiate a 'Go-Around' to correct the aforementioned deviations. Additionally, the AIB president also found sufficient evidence that skill-based errors, judgment and decision-making errors, cognitive factors, psycho-behavioural factors, coordination, communication and planning factors, and planning inappropriate operations all were substantially contributing factors to the mishap.

Crash of a PZL-Mielec M-28-05PI in Mulia: 4 killed

Date & Time: Nov 2, 2009 at 1200 LT
Type of aircraft:
Operator:
Registration:
P-4202
Flight Type:
Survivors:
No
Site:
Schedule:
Jayapura – Mulia
MSN:
AJE003-04
YOM:
2004
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The twin engine aircraft departed Jayapura-Sentani Airport on a flight to Mulia, carrying four crew members and a load of logistics support dedicated to the Puncak Jaya Police Department. While approaching Mulia in marginal weather conditions, the aircraft struck the slope of a mountain located 33 km northwest of Mulia. The wreckage was found two days later and all four occupants were killed.
Probable cause:
Controlled flight into terrain.

Crash of a BAe 125-800B in Minsk: 5 killed

Date & Time: Oct 26, 2009 at 2134 LT
Type of aircraft:
Operator:
Registration:
RA-02807
Survivors:
No
Schedule:
Moscow - Minsk
MSN:
258076
YOM:
1986
Flight number:
RLS9607
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
11926
Captain / Total hours on type:
811.00
Copilot / Total flying hours:
2356
Copilot / Total hours on type:
811
Aircraft flight hours:
12751
Aircraft flight cycles:
7979
Circumstances:
Following an uneventful flight from Moscow-Vnukovo Airport, the crew started a night approach to Minsk-2 Airport runway 31. On approach, the crew encountered poor visibility due to marginal weather. The 'Pull Up' alarm sounded and the captain initiated a go-around procedure. Few minutes later, the crew attempted a second approach to land. At an altitude of about 550 metres, the crew realized he was on the wrong ILS frequency and corrected it. On final, the EGPWS alarm sounded for 35 seconds but the captain decided to continue the approach until the aircraft impacted trees and crashed in a wooded area located 3 km short of runway, bursting into flames. The aircraft was destroyed by a post crash fire and all five occupants were killed.
Probable cause:
The cause of the crash of BAe-125-800B RA-02807 during the ILS approach procedure at night, in weather conditions that met ICAO CAT I, was the failure to take timely action by the crew to carry out a missed approach, or divert to an alternate, when the ground could not be seen while descending below decision height during a transition to visual flight, and the lack of a proper response and action required when the TAWS alarm repeatedly sounded, which led to the collision of the aircraft with obstacles (forest) and land in a controlled flight (CFIT), its destruction and death of people on board.

Contributing factors were:
- Deficiencies in the type of retraining and training of the flight crew, especially in the use of automatic flight modes, and flight director;
- Erroneous actions of the captain, which led to an execution of the approach with the wrong ILS frequency set on the left set;
- Lack of preparation of the commander of the plane for an approach in weather conditions that meet CAT I ICAO.
Values of meteorological conditions in the flight log were in most cases were falsified;
- Poor communication and crew resource management (CRM) of the flightcrew;
- Poor control of the level of training of the crew by the airline's management and lack of organization in the airline's flight operations;
- Psychological characteristics of the pilots, unrecorded in the formation of the crew and, possibly, reduced efficiency of the captain in a stressful situation because of chronic ischemic heart disease with coronary artery problems, which was not detected when passing aviation medical checks.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Zephyrhills: 3 killed

Date & Time: Oct 23, 2009 at 2017 LT
Registration:
N98ZZ
Flight Type:
Survivors:
No
Schedule:
Gainesville – Lakeland
MSN:
46-36169
YOM:
1998
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2750
Captain / Total hours on type:
110.00
Aircraft flight hours:
1893
Circumstances:
The pilot fueled the airplane prior to departure and flew uneventfully for approximately 30 minutes. The airplane then descended to 2,000 feet on approach to the destination airport, during night visual meteorological conditions. About 30 seconds after being cleared for a visual approach, the pilot declared an emergency to air traffic control and requested assistance to the nearest airport. The controller provided a vector to divert and distance to the nearest suitable airport. The pilot subsequently reported "engine out, engine out" and the airplane impacted wooded terrain about 4 miles northeast of runway 22 at the alternate airport. A post crash fire consumed a majority of the wreckage. Examination of the wreckage, including teardown examination of the engine, did not reveal any preimpact mechanical malfunctions; however, the fuel system and ignition system were consumed by post crash fire and could not be tested.
Probable cause:
A total loss of engine power during a night approach for undetermined reasons.
Final Report:

Crash of a Britten-Norman BN-2A-8 Islander off Kralendijk: 1 killed

Date & Time: Oct 22, 2009 at 1017 LT
Type of aircraft:
Operator:
Registration:
PJ-SUN
Survivors:
Yes
Schedule:
Willemstad – Kralendijk
MSN:
377
YOM:
1973
Flight number:
DVR014
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
1738
Captain / Total hours on type:
565.00
Aircraft flight hours:
16670
Circumstances:
On 22 October the pilot concerned got up at 05.00 and drove towards the airport at about 05.30. After preparing the aircraft, with registration PJ-SUN, he piloted two return flights from Curaçao International Airport (hereinafter to be referred to as Hato airport) to Bonaire International Airport (hereinafter to be referred to as Flamingo airport). No problems occurred during these four flights. The departure for the next flight, “DVR014”, was planned at 09.30. The nine passengers booked for this flight, who had already had their luggage weighed, had to wait before they could board because the pilot had ordered the aircraft to be refuelled prior to this flight. The refuelling invoice of flight DVR014 specifies that fuel was taken up between 09.28 and 09.38. The luggage of these passengers and some additional cargo consisting of a few boxes had already been loaded on to the aircraft. The passengers were welcomed by the pilot when they boarded. The pilot informed them they should keep their waist belts fastened during the flight and that the safety cards were located in the seat pockets. From the passenger statements it can be deduced that these instructions were not heard by all of the passengers. The pilot and the passenger seated next to him fastened their waist and shoulder belts. Approximately ten minutes after the estimated time of departure, after having received the required approval from the Hato Tower air traffic control tower (hereinafter to be referred to as Hato Tower) via the on-board radio the engines were started without any problems. The flight manual engine ground checks were not extensively performed because these are part of the first flight of the day engine checks in accordance with the General Operating Manual. Around 09.47 the PJ-SUN took off for a flight with visual flight rules (VFR) to Bonaire. After take-off the aircraft climbed to flight level 035 (FL035). Some of the passengers had flown for some years, several times in a week with Divi Divi Air. From the passenger statements it can be deduced that the pilot brought the aircraft into level flight at FL035 and reduced the power from climb power to cruise power. The passenger next to the pilot stated that engine power ceased the moment that the pilot was adjusting (one of) the levers on the throttle quadrant. Some passengers reported they felt a jolt that moment. Some passengers reported the engine sputtered shortly before it ceased. No sound from which a mechanical problem was heard and no smoke was detected. Passengers stated that the pilot increased the left engine power, feathered the right propeller and trimmed away the forces to the rudder pedals due to the failure of the right engine. They also reported that the pilot attempted to restart the right engine two or three times but to no avail. Around 09.52 the pilot reported to the Hato Tower controller: Divi 014 requesting to switch to Flamingo, priority landing with Flamingo, have lost one of the engines. The controller acknowledged this message. The pilot continued the flight to Bonaire flying with the left engine running and contacted Flamingo Tower air traffic control (hereinafter to be referred to as Flamingo Tower) at 09.57 and reported: 014, Islander inbound from Curaçao, showing, I got one engine out, so we are landing with one engine, no emergency at this stage, I’m maintaining altitude at, 3000 feet, we request priority to landing runway 10, currently 24 miles out, estimating at, 18. The Flamingo Tower controller authorized the approach to runway 10. The air traffic controller requested the pilot to report when he left 3000 feet altitude, which he immediately did. The radar data shows that the PJ-SUN descended approximately 140 feet per minute on average from the moment the engine failed up to the emergency landing. According to the statements of a few of the passengers, the aircraft pitch attitude increased during the descent of the aircraft and it was higher than usual. The indicated airspeed on the airspeed indicator was lower than when flying with two working engines. The pilot did not inform the passengers regarding the failure of the right engine or his intentions. A few passengers were concerned and started to put on the life jackets having retrieved them from under their seats. The passenger next to the pilot could not find his life jacket, while others had some trouble opening the plastic bags of the life jackets. They also agreed on a course of action for leaving the aircraft in case of an emergency landing in the water. At 10.08 the pilot informed the Flamingo Tower that he was approaching and was ten nautical miles away, flying at 1000 feet and expected to land in ten minutes. At 10.12 the pilot reported the distance to be eight nautical miles and that he was having trouble with the altitude which was 600 feet at that moment. The traffic controller authorized the landing. At 10.14 the pilot reported to be six nautical miles away and flying at an altitude of 300 feet. During the last radio contact at 10.15 the pilot indicated to be at five nautical miles distance flying at 200 feet and that he was still losing altitude. The pilot was going to perform an emergency landing near Klein Bonaire. The aircraft subsequently turned a little to the left towards Klein Bonaire. According to a few passengers, the pilot turned around towards them and indicated with hand signals that the aircraft was about to land and he gave a thumbs-up signal to ask whether everyone was ready for the approaching emergency landing. There were life jackets for all people on-board. The pilot, the passenger seated next to him and two passengers seated in the back row did not have their life jackets on. The passengers in rows two through to four had put on their life jackets. One passenger had put on his life jacket back to front. According to the statements of the passengers, the stall warning (loud tone) was activated on and off during this last part of the flight. A short time before the emergency landing until the moment of impact with the water the stall warning was continuously audible. From the statements of the passengers it follows the all cabin doors were closed throughout the descent and the landing. The passenger’ statements differ in describing the last part of the flight until the impact of the aircraft with the water surface. One passenger stated that the aircraft fell down from a low height and impacted the water with a blow. Other passengers mentioned a high or low aircraft pitch attitude during impact. Most of the passengers stated that during impact the left wing was slightly down. The aircraft hit the water at 10.17 at a distance of approximately 0.7 nautical miles from Klein Bonaire and 3.5 nautical miles west of Bonaire. The left front door broke off from the cabin and other parts of the aircraft on impact. The aircraft was lying horizontally in the water. The height of the waves was estimated 0.5 meter by one of the passengers. The cabin soon filled with water because the left front door had broken off and the windscreen had shattered. The passenger behind the pilot was trapped, but was able to free herself from this position. All nine passengers were able to leave the aircraft without assistance using the left front door opening and the emergency exits. A few passengers sat for a short time on the wings before the aircraft sank. The passengers formed a circle in the water. The passengers who were not wearing life jackets kept afloat by holding onto the other passengers. One passenger reported that the pilot hit his head on the vertical door/window frame in the cockpit or the instrument panel at impact causing him to lose consciousness and may even have been wounded. The attempts of one or two passengers to free the pilot from his seat were unsuccessful. A few minutes after the accident, the aircraft sank with the pilot still on-board. Approximately five minutes after the emergency landing, two boats with recreational divers who were nearby arrived on the scene. Divers from the first boat tried to localise the sunken aircraft based on indications from the passengers. The people on the other boat took nine passengers out of the water and set course to Kralendijk where they arrived at approximately 10.37. The police and other emergency services personnel were awaiting the passengers on the quay. Six passengers were transported to the hospital where they were discharged after an examination. The other three went their own way.
Probable cause:
The following factors were identified:
1. After one of the two engines failed, the flight continued to Bonaire. By not returning to the nearby situated departure airport, the safest flight operation was not chosen.
- Continuing to fly after engine failure was contrary to the general principle for twin-engine aircraft as set down in the CARNA, that is, to land at the nearest suitable airport.
2. The aircraft could not maintain horizontal flight when it continued with the flight and an emergency landing at sea became unavoidable.
- The aircraft departed with an overload of 9% when compared to the maximum structural take-off weight of 6600 lb. The pilot who was himself responsible (self-dispatch and release) for the loading of the aircraft was aware of the overloading or could have been aware of this. A non-acceptable risk was taken by continuing the flight under these conditions where the aircraft could not maintain altitude due to the overloading.
3. The pilot did not act as could be expected when executing the flight and preparing for the emergency landing.
- The landing was executed with flaps up and, therefore, the aircraft had a higher landing speed.
- The pilot ensured insufficiently that the passengers had understood the safety instructions after boarding.
- The pilot undertook insufficient attempts to inform passengers about the approaching emergency landing at sea after the engine failure and, therefore, they could not prepare themselves sufficiently.

Contributing factors:
Divi Divi Air
4. Divi Divi Air management paid insufficient supervision to the safety of amongst others the flight operation with the Britten-Norman Islanders. This resulted in insufficient attention to the risks of overloading.
Findings:
- The maximum structural take-off weight of 6600 lb was used as limit during the flight operation. Although this was accepted by the oversight authority, formal consent was not
granted for this.
- A standard average passenger weight of 160 lb was used on the load and balance sheet while the actual average passenger weight was significantly higher. This meant that passenger weight was often lower on paper than was the case in reality.
- A take-off weight of exactly 6600 lb completed on the load and balance sheet occurred in 32% of the investigated flights. This is a strong indication that the luggage and fuel weights completed were incorrect in these cases and that, in reality, the maximum structural take-off weight of 6600 lb was exceeded.
- Exceedances of the maximum structural landing weight of 6300 lb occurred in 61% of the investigated flights.
- The exceedance of the maximum allowed take-off weight took place on all three of the Britten-Norman Islander aircraft in use and with different pilots.
- Insufficient attention was paid to aircraft weight limitations during training.
- Lack of internal supervision with regard to the load and balance programme.
- Combining management tasks at Divi Divi Air, which may have meant that insufficient details were defined regarding the related responsibilities.
5. The safety equipment and instructions on-board the Britten-Norman Islander aircraft currently being used were not in order.
Findings:
- Due to the high noise level in the cabin during the flight it is difficult to communicate with the passengers during an emergency situation.
- The safety instruction cards did not include an illustration of the pouches under the seats nor instructions on how to open these pouches. The life jacket was shown with two and not a single waist belt and the life jackets had a different back than the actual life jackets on-board.
Directorate of Civil Aviation Netherlands Antilles (currently the Curaçao Civil Aviation Authority)
6. The Directorate of Civil Aviation’s oversight on the operational management of Divi Divi Air was insufficient in relation to the air operator certificate involving the Britten-Norman Islander aircraft in use.
Findings:
- The operational restrictions that formed the basis for using 6600 lb were missing in the air operator certificate, in the certificate of airworthiness of the PJ-SUN and in the approved General Operating Manual of Divi Divi Air. The restrictions entail that flying is only allowed during daylight, under visual meteorological conditions, and when a route is flown from where a safe emergency landing can be executed in case of engine failure.
- The required (demonstrable) relation with the actual average passenger weight was missing in relation to the used standard passenger weight for drawing up the load and balance sheet.
- The failure of Divi Divi Air’s internal supervision system for the load and balance programme.
- Not noticing deviations between the (approved) safety instruction cards and the life jackets on-board during annual inspections.
- The standard average passenger weight of 176 lb set after the accident offers insufficient security that the exceedance of the maximum allowed take-off weight of flights with Antillean airline companies that fly with the Britten-Norman Islander will not occur.

Other factors:
Recording system of radio communication with Hato Tower
7. The recording system used for the radio communication with Hato Tower cannot be used to record the actual time. This means that the timeline related to the radio communication with Hato Tower cannot be exactly determined.
The alerting and the emergency services on Bonaire
8. There was limited coordination between the different emergency services and, therefore, they did not operate optimally.
Findings:
- The incident site command (Copi) that should have taken charge of the emergency services in accordance with the Bonaire island territory crisis plan was not formed.
- Insufficient multidisciplinary drills have been organized and assessed for executive officials who have a task to perform in accordance with the Bonaire island territory crisis plan and the airport aircraft accident crisis response plan in controlling disasters and serious accidents. They were, therefore, insufficiently prepared for their task.
9. The fire service and police boats could not be deployed for a longer period of time.
Final Report: