Crash of a Carvair ATL-98 in Nixon Fork Mine

Date & Time: May 30, 2007 at 1200 LT
Operator:
Registration:
N898AT
Flight Type:
Survivors:
Yes
Schedule:
Fairbanks - Nixon Fork Mine
MSN:
42994
YOM:
1946
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21658
Captain / Total hours on type:
13600.00
Aircraft flight hours:
55753
Circumstances:
The captain was making a VFR landing approach to a remote mining airstrip in a modified Douglas DC-4 airplane at the end of a cross-country nonscheduled cargo flight. The modified airplane had a raised cockpit above the fuselage to accommodate an upward swinging nose door. During the landing flare/touchdown, the airplane undershot the runway threshold, and right main landing gear struck the lip of the runway. The right main landing gear was torn off, which allowed the nose and right wing to collide with the runway surface. The right wing was torn off the fuselage and caught fire. The fuselage, containing the cargo of fuel bladders, slid to a stop and rolled about 90 degrees to the left. The pilot indicated that due to the additional cockpit height of the modified airplane, versus a standard Douglas DC-4 airplane, the airplane was lower than he perceived.
Probable cause:
An undershoot and collision with the runway when the pilot misjudged the distance/altitude during the landing flare/touchdown.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter in Pampa Hermosa: 13 killed

Date & Time: May 24, 2007 at 1745 LT
Operator:
Registration:
FAP-303
Flight Type:
Survivors:
Yes
Site:
Schedule:
Iquitos – Requena – Orellana – Pampa Hermosa – Contamana – Pucallpa
MSN:
483
YOM:
1976
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
13
Circumstances:
The Twin Otter departed Iquitos Airport at 1137LT on a flight to Pucallpa with intermediate stops in Requena, Orellana, Pampa Hermosa and Contamana. While descending to Pampa Hermosa in marginal weather conditions, the aircraft crashed in a mountainous area located few km from the airport. Seven passengers were rescued while 13 other occupants were killed.

Crash of a Canadair RegionalJet CRJ-100ER in Toronto

Date & Time: May 20, 2007 at 1235 LT
Operator:
Registration:
C-FRIL
Survivors:
Yes
Schedule:
Moncton – Toronto
MSN:
7051
YOM:
1994
Flight number:
AC8911
Country:
Crew on board:
37
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft, with 3 crew members and 37 passengers on board, was operating as Air Canada Jazz Flight 8911 from Moncton, New Brunswick, to Toronto/Lester B. Pearson International Airport, Ontario. At 1235 eastern daylight time, the aircraft landed on Runway 06R with a 90º crosswind from the left, gusting from 13 to 23 knots. The aircraft first contacted the runway in a left-wing-down sideslip. The left main landing gear struck the runway first and the aircraft sustained a sharp lateral side load before bouncing. Once airborne again, the flight and ground spoilers deployed and the aircraft landed hard. Both main landing gear trunnion fittings failed and the landing gear collapsed. The aircraft remained upright, supported by the landing gear struts and wheels. The aircraft slid down the runway and exited via a taxiway, where the passengers deplaned. There was no fire. There were no injuries to the crew; some passengers reported minor injuries as a result of the hard landing.
Probable cause:
Findings as to Causes and Contributing Factors:
1. On final approach, the captain diverted his attention from monitoring the flight, leaving most of the decision making and control of the aircraft to the first officer, who was significantly less experienced on the aircraft type. As a result, the first officer was not fully supervised during the late stages of the approach.
2. The first officer did not adhere to the Air Canada Jazz standard operating procedures (SOPs) in the handling of the autopilot and thrust levers on short final, which left the aircraft highly susceptible to a bounce, and without the bounce protection normally provided by the ground lift dump (GLD) system.
3. Neither the aircraft operating manual nor the training that both pilots had received mentioned the importance of conducting a balked or rejected landing when the aircraft bounces. Given the low-energy state of the aircraft at the time of the bounce, the first officer attempted to salvage the landing.
4. When the thrust levers were reduced to idle after the bounce, the GLD system activated. The resultant sink rate after the GLD system deployed was beyond the certification standard for the landing gear and resulted in the landing gear trunnion fitting failures.
5. There was insufficient quality control at the landing gear overhaul facility, which allowed non-airworthy equipment to enter into service. The condition of the shock struts would have contributed to the bounce.
Findings as to Risk:
1. Several passengers took carry-on items with them as they exited the aircraft, despite being instructed not to do so.
2. The location of the stored megaphone did not allow the flight attendant to have ready access after the passengers started moving to the exit door.
Final Report:

Crash of a Cessna 404 Titan II in Goroka

Date & Time: May 19, 2007
Type of aircraft:
Operator:
Registration:
P2-ALK
Survivors:
Yes
MSN:
404-0222
YOM:
1978
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the pilot started the approach to Goroka Airport in poor weather conditions. After landing on runway 17R, the aircraft was unable to stop within the remaining distance. It overran and came to rest few dozen metres further. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 550 Citation II in Dillon: 2 killed

Date & Time: May 3, 2007 at 1037 LT
Type of aircraft:
Operator:
Registration:
N22HP
Flight Type:
Survivors:
No
Schedule:
Rockford - Dillon
MSN:
550-0103
YOM:
1986
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5057
Captain / Total hours on type:
1200.00
Aircraft flight hours:
10526
Circumstances:
Radar data indicated that the airplane descended on a straight track from flight level (FL) 380 in accordance with the pilot's clearance to descend to 13,000 feet and begin the VOR (very high frequency omni-directional radio range) approach to the destination airport. The last transmission from the pilot was an acknowledgment of the cancellation of radar service and an instruction to switch to the airport advisory frequency. At that time, the airplane was at a mode C reported altitude of 14,000 feet. The airplane maintained a steady descent rate for the next minute and leveled off at 13,000 feet. About 2 1/2 minutes later, the airplane began a turn to the right to head outbound for the procedure turn on the approach and descended to 12,900 feet. The approach procedure specified a minimum altitude of 8,200 feet in the procedure turn. The airplane lost 1,600 feet in the next 10 seconds, and this was the last radar contact. A witness working in his office at the airport heard a loud engine noise, and then a “plop” noise. He said that the engine noise was loud, then softer, and then loud again. He heard it for 3 to 5 seconds. Another witness saw an airplane below the cloud bases that was turning to the right with a nose low pitch attitude of about 75 to 80 degrees. It made six to seven turns before it disappeared from sight behind terrain, and the radius of the turn got tighter as the airplane descended. Examination of the airframe, systems, and engines revealed no anomalies that would have precluded normal operation. Anti-ice fluid was on the leading edges of the wing and tail anti-ice panels. An Airmen’s Meteorological Information (AIRMET) in effect for an area that included the accident site noted that the freezing level was from 4,000 to 10,000 feet with the potential for icing from the freezing level to 20,000 feet.
Probable cause:
An in-flight loss of control for undetermined reasons.
Final Report:

Crash of a Britten-Norman BN-2A-27 Islander in Kopinang: 3 killed

Date & Time: Apr 25, 2007 at 1405 LT
Type of aircraft:
Operator:
Registration:
8R-GET
Survivors:
Yes
Schedule:
Ogle – Kato – Kopinang – Mahdia – Ogle
MSN:
484
YOM:
1976
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Ogle on a schedule service to Kato, Kopinang and Mahdia. At Kato Airport, the pilot and passengers should wait more than two hours for weather improvement. The aircraft departed Kato at 1345LT on the leg to Kopinang with four passengers, two adults, a five-year old boy and an infant. Twenty minutes later, while on approach to Kopinang, the aircraft descended into trees and crashed in a dense wooded area located few km from the airfield. The wreckage was found few hours later. Two passengers were seriously injured while the pilot and two passengers including the infant were killed.

Crash of a Piper PA-31-310 Navajo in Revelstoke

Date & Time: Apr 23, 2007 at 1421 LT
Type of aircraft:
Operator:
Registration:
C-GVSG
Flight Type:
Survivors:
Yes
Schedule:
Vancouver - Revelstoke
MSN:
31-418
YOM:
1969
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot and the passenger, a photographer, departed Vancouver at 0911LT with 5.5 hours of fuel to conduct a VFR aerial photographic flight over the Arrow Lakes area. At 1420LT, the aircraft entered the circuit at Revelstoke Airport to refuel and to allow the photographer to change camera film. The pilot reportedly selected the landing gear down as the aircraft turned base and heard the gear clunk into position. When the aircraft turned final however, the red in-transit light was illuminated and the nose gear was not visible in the mirror. The pilot selected the gear lever up and down a couple of times but the gear did not extend. When the pilot advanced the throttles to conduct an overshoot, both engines surged and sputtered. The pilot retarded the throttles and conducted a gear-up landing in a grassy area off the end of runway 30. During the landing, the dry 8-inch high grass caught fire. Both occupants escaped from the aircraft that was destroyed by ground fire.

Crash of a De Havilland Dash-8-301 in Governor's Harbour

Date & Time: Apr 20, 2007 at 1708 LT
Operator:
Registration:
C6-BFN
Survivors:
Yes
Schedule:
Nassau – Governor’s Harbour
MSN:
159
YOM:
1989
Flight number:
UP353
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
29570
Aircraft flight cycles:
52653
Circumstances:
Following an uneventful flight (service UP353) from Nassau, the crew started the descent to Governor’s Harbour. After landing on runway 15, the left main gear collapsed. The aircraft slid for few dozen metres then turn slightly to the left and came to rest on the main runway. All 51 occupants evacuated safely, nevertheless, few passengers suffered minor injuries. The aircraft was damaged beyond repair.
Probable cause:
The probable Cause has been determined as an over-center Torque Link condition that culminated in a single cycle failure of the cylinder. The over center torque links condition occur as a result of the over extension of the shock strut.
Possible Contributory factors to the over extension of the shock strut includes:
Possible Cause for Loss of Damping
• The failure to install the dampening ring when the landing gear was assembled.
• Improper servicing of the landing gear shock strut with Mil-H-5606 hydraulic fluid plus nitrogen during initial assembly.
• Improper servicing of landing gear shock strut during line maintenance and inadequate post servicing follow up per AMM Chapter 12. See attached report Appendix A-30 From Bombardier
• Under-serviced shock strut (low oil volume)
• A broken damper ring
• No damper ring
• Disengaged damper ring.
Final Report:

Crash of a Pilatus PC-6/B1-H2 Turbo Porter in Casas de Los Pinos

Date & Time: Apr 14, 2007 at 1015 LT
Operator:
Registration:
EC-JOE
Survivors:
Yes
Schedule:
Casas de Los Pinos - Casas de Los Pinos
MSN:
705
YOM:
1969
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
650
Captain / Total hours on type:
138.00
Aircraft flight hours:
9046
Circumstances:
The aircraft ran off runway 30 at the Casas de los Pinos aerodrome while landing. The aircraft, used for parachuting operations, was making a reconnaissance flight before the parachuting flights, which were scheduled for later. According to the pilot's statement, during the flare, and before touching down, a gust of wind lifted the left wing. The pilot used left rudder and tilt to try to level the aircraft, but could not keep it from exiting the runway. As stated by the pilot, the approach was performed without flaps, at a speed of 70 knots and with the aft gear locked. The aircraft ended up 25 metres from the edge of the runway on a heading of 190°, resting on its lower fuselage, which was damaged along its underside, as were the left aileron and the horizontal stabilizer. The right main landing gear was bent outward, the left gear had detached and was 30 metres away from the aircraft, and the propeller had detached at the reduction gearbox and was next to the aft landing gear to the left of the aircraft. Both occupants were able to exit the aircraft under their own power. The pilot received a slight injury to his chin and the passenger was unhurt.
Probable cause:
It is not known why aircraft EC-JOE left runway 30 during the landing, though it seems obvious that the aircraft's path was altered while it was flying at a low altitude. The possibility that a technical problem with the aircraft caused the accident has been ruled out. It has not been possible to confirm if the wind was gusting at the aerodrome at the time of the accident, though even gusty conditions should not have affected control of the aircraft since its airspeed was high enough with respect to the stall speed.
Final Report:

Crash of a Beechcraft 200 Super King Air in Perth

Date & Time: Apr 9, 2007 at 1703 LT
Operator:
Registration:
VH-SGT
Survivors:
Yes
Schedule:
Perth - Mount Hale
MSN:
BB-73
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 9 April 2007, at 1703 Western Standard Time (WST), the main landing gear from a Beech Super King Air 200 aircraft, registered VH-SGT, collapsed on landing at Perth airport. Approximately two hours earlier, the aircraft was chartered to fly from Perth to Mount Hale, WA when shortly after takeoff from Perth the aircraft experienced a malfunction of the landing gear system. The main wheels and nose gear had become jammed and were unable to fully retract when selected up by the pilot. The pilot completed the emergency checklist actions contained in the Aircraft Flight Manual, but was unable to retract or extend the gear using either the automated control or the manual emergency system. The pilot then requested assistance from a passenger to operate the manual emergency extension system. The landing gear remained jammed despite the additional force applied to the lever from the passenger. The pilot contacted air traffic services and requested further assistance from company engineering personnel to visually assess the extension state of the landing gear. Two aerodrome passes were completed throughout the troubleshooting exercise and the pilot remained in radio contact with both groups during this phase. Following the flyovers and after holding over Rottnest Island at 5,000 ft for a period of approximately two hours, the pilot flew the King Air back to Perth airport. With the gear still jammed in the partially retracted position, both the left and right main landing gear assemblies collapsed after the aircraft touched down on Runway 24. The aircraft was substantially damaged as a result of the collapse (Figure 1). The airport Rescue and Fire Fighting (RFF) services and other relevant agencies had been alerted and were waiting in response when the King Air landed. No injuries were sustained by the pilot or any of the nine passengers on board.
Probable cause:
From the evidence available, the investigation revealed that two major system components had failed which could have prevented the Beechcraft Super King Air 200 landing gear from properly retracting after takeoff. The following findings with respect to those failed landing gear system components should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• The left torque tube support bearing had not been lubricated and had seized due to the accumulation of dirt and grit contaminants that had migrated from the external service environment and into the bearing.
• The geared components within the right main landing gear actuator prematurely failed.
Other safety factors:
• The aircraft manufacturer’s maintenance manual contained insufficient instruction or guidance for operators and maintainers of Super King Air 200 aircraft for the lubrication of the landing gear torque tube support bearings.
Other key findings:
• Both component assemblies were integral to the function and normal operation of the Super King Air 200 mechanical landing gear system. A break down of either component assembly would have prevented any attempt by the pilot to retract or extend the aircraft’s main landing gear. However, while either failure could have produced the landing gear difficulties sustained, the investigation was not able to determine which mechanism was the principal contributor to the event.
• The investigation was unable to conclusively establish why the geared components within the right main landing gear actuator had prematurely failed.
• The lower thrust bearing within the right main landing gear actuator had been correctly installed.
Final Report: