Crash of a NAMC YS-11-500R in Mae Sot

Date & Time: Sep 11, 2005 at 0900 LT
Type of aircraft:
Operator:
Registration:
HS-KVO
Survivors:
Yes
Schedule:
Bangkok – Mae Sot
MSN:
2116
YOM:
1969
Flight number:
VAP326
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
24
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach and landing at Mae Sot Airport were completed in rainy conditions. After touchdown, the aircraft was unable to stop within the remaining distance, collided with a fence and came to rest. All 28 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
On final approach, the aircraft was too high and landed too far down the runway at an excessive speed. The runway surface was wet and the braking action was poor.

Crash of a Cessna 501 Citation I/SP in Rome

Date & Time: Sep 9, 2005 at 1830 LT
Type of aircraft:
Operator:
Registration:
I-AROM
Survivors:
Yes
Schedule:
Lugano – Rome
MSN:
501-0042
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 15 (2,207 metres long) at Rome-Ciampino Airport, the aircraft was unable to stop within the remaining distance. It overran, collided with the localizer antenna and came to rest. While the aircraft was considered as damaged beyond repair, all five occupants escaped uninjured. It was raining at the time of the accident and the runway was wet.

Crash of a Britten-Norman BN-2B-20 Islander in Samarinda

Date & Time: Sep 9, 2005 at 1115 LT
Type of aircraft:
Operator:
Registration:
PK-VIA
Flight Type:
Survivors:
Yes
Schedule:
Samarinda - Samarinda
MSN:
2250
YOM:
1992
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew was completing a local training flight at Samarinda Airport. While on a fourth approach, the twin engine airplane stalled and crashed on a softball field located in the Segiri sports complex near the airport. Both pilots were injured and the aircraft was destroyed.

Crash of an Antonov AN-26B in Isiro: 11 killed

Date & Time: Sep 5, 2005 at 0730 LT
Type of aircraft:
Registration:
ER-AZT
Flight Type:
Survivors:
No
Schedule:
Beni – Isiro
MSN:
90 05
YOM:
1979
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
11
Circumstances:
On final approach to Isiro Airport, the crew encountered poor visibility due to fog. Too low, the aircraft collided with a palm tree and crashed 1,500 metres short of runway 31. All 11 occupants were killed.

Crash of a Cessna 441 Conquest in Anchorage

Date & Time: Aug 28, 2005 at 2129 LT
Type of aircraft:
Operator:
Registration:
N77SA
Flight Type:
Survivors:
Yes
Schedule:
Cordova - Anchorage
MSN:
441-0329
YOM:
1983
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17000
Captain / Total hours on type:
50.00
Aircraft flight hours:
11049
Circumstances:
The airline transport pilot was landing a retractable landing gear-equipped turboprop airplane on a 10,900 foot long, by 150 foot wide paved runway. According to the pilot, while on approach to land, he selected 10 degrees of wing flaps, and then selected the landing gear selector switch to the down position, which was followed by "three greens", indicating the landing gear was down, locked, and safe for landing. He said that after touchdown, during the initial landing roll, the landing gear retracted, and the airplane slid on the underside of the fuselage. The airplane veered to the right of the runway centerline, and the right wing collided with numerous runway edge lights. A post crash fire ensued when the right wing's fuel tank was breached. The airplane received structural damage to the underside of the fuselage, and the right wing was destroyed. Propeller strike marks originated in the vicinity of the accident airplane's touchdown point, and extended to the airplane's final resting point, about 2,200 feet from initial contact. A postaccident inspection of the airplane by the IIC and another NTSB air safety investigator, disclosed no evidence of any pre accident mechanical malfunction of the landing gear assembly or its associated operating systems. The airplane was placed on jack stands and hydraulic pressure was supplied to the airplane's hydraulic system using a hydraulic ground power unit. The airplane's landing gear retraction system was cycled numerous times, with no mechanical anomalies noted.
Probable cause:
The pilot's failure to lower the airplane's landing gear during landing, which resulted in an inadvertent wheels up landing.
Final Report:

Crash of a Boeing 737-244 in Pucallpa: 40 killed

Date & Time: Aug 23, 2005 at 1509 LT
Type of aircraft:
Operator:
Registration:
OB-1809-P
Survivors:
Yes
Schedule:
Lima - Pucallpa - Iquitos
MSN:
22580
YOM:
1981
Flight number:
TJ204
Country:
Crew on board:
7
Crew fatalities:
Pax on board:
91
Pax fatalities:
Other fatalities:
Total fatalities:
40
Captain / Total flying hours:
5867
Captain / Total hours on type:
3763.00
Copilot / Total flying hours:
4755
Copilot / Total hours on type:
1109
Aircraft flight hours:
49865
Aircraft flight cycles:
45262
Circumstances:
Following an uneventful flight from Lima, the aircraft was descending to Pucallpa-Capitán David Abensur Rengifo Airport runway 02, an intermediate stop on the flight from Lima to Iquitos. As the crew approached the destination, weather conditions deteriorated with heavy rain falls, CB's and turbulences. On final approach, the aircraft was unstable and descended below the glide until it crashed in a swampy and wooded area located 3,5 km short of runway. The aircraft was destroyed by impact forces and a post crash fire. 58 people were injured, some seriously, while 40 other occupants including five crew members were killed, among them 34 Peruvian, three American, one Australian, one Colombian and one Spanish.
Probable cause:
The Commission determines the likely cause of the accident as follows:
- The decision of the flight crew to continue the final approach and landing at the airport of Pucallpa in severe weather (storm).
- The decision of the flight crew to descend unstabilized and not act to stop the steep descent to the ground at a descent rate of above 1500 feet per minute; what triggered the GPWS (Ground Proximity Warning System).
- The decision of the flight crew not avoid the storm, not choosing to conduct a landing on the other runway or divert to the nearest airport until weather conditions improved.
- The decision of the flight crew to penetrate the storm, it having been detected on weather radar aircraft approximately 190 miles in advance.
- The loss of the horizontal and vertical visibility of the flight crew while penetrating the core of the storm (severe hailstorm). Severe hail causes obscuration of the front windows of the aircraft and therefore the total loss of situational awareness.
Final Report:

Crash of a Britten-Norman BN-2B-27 Islander in Durban

Date & Time: Aug 21, 2005 at 1300 LT
Type of aircraft:
Operator:
Registration:
ZS-PCJ
Survivors:
Yes
Site:
Schedule:
Manzengwenya – Durban
MSN:
869
YOM:
1978
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
950
Captain / Total hours on type:
6.00
Aircraft flight hours:
7670
Circumstances:
The pilot accompanied by five passengers took off from Manzengwenya Aerodrome on a chartered flight to Virginia Aerodrome, (FAVG). The pilot reported that although it was drizzling, visibility was good. He reported his position to the FAVG Air Traffic Controller and requested joining instructions to FAVG. The ATC cleared the pilot to land on Runway 05. When he was on short finals, the tower noticed that the aircraft was drifting away from the runway centerline and called the pilot. The pilot stated that he is experiencing an engine problems and he is initiating a go around. The aircraft turned out to the left and away from the runway centerline, and the pilot allowed the aircraft to continue flying over the nearby “M4” highway and then towards a residential area. The aircraft then impacted the roof of a private residential property, (house) with its left wing first and the nose section. It came to rest in a tail high and inverted position. Although the wreckage was still fairly intact, both the aircraft and the residential property were extensively damaged. The aircraft’s left wing failed outboard of the engine on impact. The nose of the aircraft as well as the cabin instrumentation area was crushed towards the front seated passengers. Both main wing spars, the nose wheel, the engine mounts, the propellers, and the fuselage were also damaged. The aircraft had a valid Certificate of Airworthiness which was issued on 17 September 2004 with an expiry date of 16 September 2005. The last Mandatory Periodic Inspection was certified on 03 September 2004 at 7594.2 airframe hours and he aircraft had accumulated a further 75.8 hours since the last MPI was certified. The aircraft was recovered to an Approved AMO for further investigation. Both flight and engine controls were found satisfactory. Ground run test were conducted with both engines still installed to the aircraft, and both engines performed satisfactorily during these performance tests. The Aircraft Maintenance Organisation was audited in the last two years and the last audit was on 01 July 2005.
Probable cause:
The pilot employed a incorrect go-around technique and took inappropriate actions during the emergency situation, which aggravated the situation.
Contributory Factors:
- Prevalent carburettor icing probability conditions for any power setting.
- Lack of experience of the pilot on the aircraft type.
Final Report:

Crash of a Boeing 747-251B in Agana

Date & Time: Aug 19, 2005 at 1418 LT
Type of aircraft:
Operator:
Registration:
N627US
Survivors:
Yes
Schedule:
Tokyo - Agana
MSN:
21709
YOM:
1979
Flight number:
NW074
Country:
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
324
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7850
Captain / Total hours on type:
7850.00
Copilot / Total flying hours:
9100
Copilot / Total hours on type:
8695
Aircraft flight hours:
95270
Circumstances:
During the initial approach, the red GEAR annunciator light above the gear lever illuminated, and the landing gear warning horn sounded after the gear handle was selected down and the flaps were selected to 25 degrees. During the go-around, the captain asked the second officer (SO), "what do you have for the gear lights?" The SO responded, "four here." When all gear are down and locked on the Boeing 747-200, the landing gear indication module located on the SO’s instrument panel has five green lights: one nose gear light above four main landing gear lights. The crew then read through the "Red Gear Light Remains On (After Gear Extension)" emergency/abnormal procedure from the cockpit operations manual to troubleshoot the problem. Although the checklist twice presented in boldface type that five lights must be present for the gear to be considered down and locked, the crew did not verbalize the phrase either time. The captain did not directly request a count, and the SO did not verbally confirm, the number of gear down annunciator lights that were illuminated; instead, the flight crew made only general comments regarding the gear, such as "all gear," "all green," or "got 'em all." Because the crew believed that all of the gear annunciator lights were illuminated, they considered all gear down and locked and decided not to recycle the landing gear or attempt to extend any of the gear via the alternate systems before attempting a second approach. During all communications with air traffic control, the flight crew did not specify the nature of the problem that they were troubleshooting. Although the checklist did not authorize a low flyby, if the flight crewmembers had verbalized that they had a gear warning, the controller most likely would have been able to notify the crew of the nose gear position before the point at which a go-around was no longer safe. Multiple gear cycles were conducted after the accident, and the nose gear extended each time with all nose gear door and downlock indications correctly displayed on the landing gear indication module. Post accident examination of the nose gear door actuator found that one of the two lock keys was installed 180 degrees backward. Although this improper configuration could prevent proper extension of the nose gear, the actuator had been installed on the accident airplane since 2001 after the actuator was overhauled by the operator. No anomalies were found with the landing gear indication module, the nose gear-operated door sequence valve, and the nose/body landing gear selector valve.
Probable cause:
The flight crews' failure to verify that the number of landing gear annunciations on the second officer’s panel was consistent with the number specified in the abnormal/emergency procedures checklist, which led to a landing with the nose gear retracted.
Final Report:

Crash of a Cessna 425 Conquest I in Denver: 4 killed

Date & Time: Aug 13, 2005 at 2020 LT
Type of aircraft:
Registration:
N425SG
Flight Type:
Survivors:
No
Schedule:
Sandpoint - Denver
MSN:
425-0166
YOM:
1982
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5000
Captain / Total hours on type:
1450.00
Aircraft flight hours:
4003
Circumstances:
During an ILS approach in night instrument meteorological conditions, the airplane impacted terrain and was destroyed by impact forces and post crash fire. Prior to departure, the pilot obtained a weather briefing, which reported light rain, mist, and instrument meteorological conditions at the destination airport. After approaching the terminal area, the pilot received radar vectors to intercept the localizer for the Runway 35R ILS approach. The pilot's keying of the microphone and the timing of his speech exhibited decreased coordination during the approach phase of flight. After crossing the outer marker and at altitude of 7,700 feet, the pilot asked the controller what the current ceilings were at the airport, and the controller stated 500 feet. With the airplane at an altitude of 6,800 feet, the controller informed the pilot of a "low altitude alert" warning, at which the pilot responded, "Yeah, I am a bit low here." Approximately 20 seconds later, the pilot stated, "I'm back on glideslope." No further communications were received from the accident airplane. The controller issued another low altitude warning, and the radar target was lost. The accident site was located on a hilly, grass field at an elevation of 6,120 feet approximately 2.6 nautical miles from the runway threshold
near the extended centerline of the runway. At 2027, the weather conditions at the airport were reported as wind from 360 degrees at 10 knots, visibility 2 statute miles with decreasing rain, scattered clouds at 500 feet, broken clouds at 1,100 feet, and an overcast ceiling at 2,800 feet. An acquaintance of the pilot, who had flown with him on other occasions, provided limited information about the pilot's proficiency, but stated, "a night ILS in IFR conditions would not be [the pilot's] first choice if he had an option." The pilot's logbooks were not located. The pilot did not hold a valid medical certificate at the time of the accident, and postaccident toxicological test revealed the presence of unreported prescription medications. No anomalies were noted with the airframe and engines. Ground inspection and flight testing of the airport's navigational equipment revealed that the equipment functioned satisfactorily.
Probable cause:
The pilot's failure to properly execute the published instrument approach procedure, which resulted in controlled flight into terrain.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Fort Lauderdale

Date & Time: Aug 13, 2005 at 1557 LT
Operator:
Registration:
N318JL
Survivors:
Yes
Schedule:
North Eleuthera - Fort Lauderdale
MSN:
31-8152033
YOM:
1981
Flight number:
TTL217
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14500
Captain / Total hours on type:
6550.00
Circumstances:
The pilot provided an emergency briefing to the passengers before departure. The outboard fuel tanks were empty and the inboard fuel tanks were filled before departure. After takeoff, the flight climbed to 8,500 feet msl and proceeded towards the destination airport. During cruise flight while flying at 1,000 feet msl approximately 10 miles from the destination airport , the left engine started losing power, but the airplane did not yaw; the left cowl flap was closed at the time. The pilot reported the left fuel flow light was on, but the fuel pressure was in the green arc (indicating approximately 38 to 42 psi). He switched each fuel selector to its respective outboard fuel tank though the outboard tanks were empty, turned on both emergency fuel pumps, and also attempted cross feeding fuel to the left engine in an effort to restore engine power but was unsuccessful. The left engine manifold pressure decreased to 18 inHg, and he was maintaining "blue line" airspeed plus a few knots with the right engine at full power. He slowed the airplane to less than blue line airspeed in an attempt to "gain altitude", and approximately 2 to 3 minutes after first noticing the loss of engine power from the left engine with the manifold pressure indication of 15 inHg, and after seeing boats nearby, he moved the left propeller control to the feather position but later reported the propeller did not feather. The left engine rpm was in the upper green arc through the whole event, and he did not see any oil coming out of the left engine cowling. The flight was unable to maintain altitude, and he advised the passengers to don but not inflate their life vests. He maneuvered the airplane into the wind near boats, and ditched with the flaps and landing gear retracted. All occupants exited the airplane and were rescued by one of the nearby boats. Each inboard fuel tank is equipped with a "surge tank" and a flapper valve, and also a sensing probe installed at the outlet of the tank. The airplane POH/AFM indicates that if the fuel flow light illuminates, and there is fuel in the corresponding tank, a malfunction of the flapper valve has occurred. The airplane was not recovered; therefore no determination could be made as to the reason for the reported loss of engine power from the left engine, nor the reason for the failure of the left propeller to feather.
Probable cause:
The reported loss of engine power from the left engine, and the failure of the left propeller to feather for undetermined reasons, resulting in the inability to maintain altitude, and subsequent ditching.
Final Report: