Crash of an Antonov AN-12 near Entebbe: 6 killed

Date & Time: Jan 8, 2005 at 1300 LT
Type of aircraft:
Operator:
Registration:
9Q-CIH
Flight Type:
Survivors:
No
Schedule:
Entebbe - Kinshasa
MSN:
4 3 418 03
YOM:
1964
Location:
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The aircraft departed Entebbe Airport at 1148LT on a cargo flight to Kinshasa, carrying six crew members and a load consisting of two cars, t-shirts and 10 tons of beans. Five minutes after takeoff, the crew informed ATC that one of the engine caught fire and was cleared to return for an emergency landing. Seven minutes later, out of control, the aircraft crashed in a wooded area located near Bukalaza, about 11 km from the airport. The aircraft disintegrated on impact and all six occupants were killed.
Probable cause:
The following findings were identified:
- The operator did not have a AOC or any licence to fly,
- The operator did not have any maintenance record or quality control program,
- There was no records regarding crew licensing and/or training,
- Poor flight preparation as the aircraft was not properly loaded,
- The CofG was outside the permissible limit (out of enveloppe).

Crash of a Boeing 737-2A9C in Banda Aceh

Date & Time: Jan 4, 2005 at 0200 LT
Type of aircraft:
Operator:
Registration:
PK-YGM
Flight Type:
Survivors:
Yes
MSN:
20206/249
YOM:
1970
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a cargo flight to Banda Aceh, taking part to relief operation following the recent tsunami that affected the Aceh province. After landing by night, the crew started the braking procedure when the aircraft collided with a buffalo. Upon impact, the left main gear was torn off and the aircraft slid for few dozen metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Collision with a buffalo upon landing.

Crash of a Cessna 551 Citation II/SP in Ainsworth

Date & Time: Jan 1, 2005 at 1120 LT
Type of aircraft:
Operator:
Registration:
N35403
Flight Type:
Survivors:
Yes
Schedule:
Reading - Ainsworth
MSN:
551-0029
YOM:
1980
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2200
Captain / Total hours on type:
475.00
Aircraft flight hours:
5870
Circumstances:
The twin-engine corporate jet impacted terrain while maneuvering to land after a global positioning system (GPS) approach. The pilot reported that the airplane entered icing conditions during the approach and that the airplane descended out of instrument meteorological conditions between 300-400 feet above ground level (agl). The pilot reported that his windshield had become obscured by ice accumulation during the approach and that he "had difficulty seeing the runway." The pilot elected to land the airplane instead of executing the published missed-approach procedure. The airplane impacted terrain 439 feet short of the runway threshold while in a right turn. After the accident, there was ice accumulation on all booted airframe surfaces measuring 2-4 inches wide and 1/4 to 3/8 inch thick. The upper portions of the windscreens were contaminated with ice measuring about 3/8 inch thick. The remaining airframe portions, including the heated surfaces, were free of ice accumulation. The windshield bleed air switch was selected on "High" with the pilot's side windshield heat control knob approximately mid-range. Windshield alcohol was selected "On", but the alcohol reservoir was still full upon inspection. At the time of the accident, there was an overcast ceiling of 500 feet agl, 1-3/4 statute mile visibility with mist, and an outside temperature of -08 degrees Celsius. The published minimum descent altitude (MDA) for the GPS runway 17 approach is 500 feet agl, for an airplane equipped with a lateral navigation only GPS receiver. The pilot held a private pilot certificate with multi-engine land, instrument airplane, and Cessna 500 type rating. The pilot reported having 2,200 hours total flight time and 475 hours in the same make/model as the accident airplane.
Probable cause:
The pilot's decision to continue below the minimum descent altitude (MDA) and his failure to fly the published missed-approach procedure. A factor to the accident was the pilot's improper use of windshield heat which resulted in the windshield becoming obscured with ice during the instrument approach in icing conditions.
Final Report:

Crash of an Ilyushin II-76TD in Dushanbe

Date & Time: Dec 30, 2004 at 0348 LT
Type of aircraft:
Operator:
Registration:
ER-IBM
Flight Type:
Survivors:
Yes
Schedule:
Billund – Baku – Kaboul
MSN:
00334 48390
YOM:
1983
Flight number:
RIN922
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Ilyushin 76 was chartered to fly a consignment of 28938 kg of humanitarian aid from Billund, Denmark to Kabul, Afghanistan. The airplane departed Billund at 18:00 and landed at Baku, Azerbaijan for a refueling stop. Visibility at Kabul was reported as 3000 m, and forecast worsening to 1200 m between 00:00 and 06:00 h due to snow and haze. Minima for Kabul airport however were a visibility of 5000 m and a cloud base at 450 m. The captain nevertheless departed Baku. While approaching Kabul the weather was reported to be: wind 340 degrees at 4 kts, visibility 2000 m, 1-2 octas clouds at 480 m, 5-7 octas clouds at 3000 m and a QNH of 1020 hPa. During the approach low clouds were moving in from the north. The visibility was limited to 500 m in fog and the wind direction changed. The crew of the Ilyushin were not informed of these changed values. The approach was continued and flaps and gear were selected down. At decision height the spoilers were extended and the descent was continued. The captain ordered the spoilers to be retracted, but this command was not carried out. At a height of 310 m, 4230 m short of the runway 29 threshold, the flaps were selected down to 43 degrees. The Il-76 was at that stage 365 m to the right of the extended centreline. The flight descended below the glideslope until it contacted the ground 910 m short of the runway threshold, at a speed of 230 km/h. The left undercarriage was destroyed and separated from the aircraft. The lower aft fuselage and cargo door were severely damaged and the pressure in the no. 1 and no. 2 hydraulic systems fell. The crew applied takeoff power, retracted the spoilers and selected flaps back to 30 degrees. The aircraft climbed away and the captain decided to head for Termez, Uzbekistan, but this airport was closed due to fog. It was decided to continue to Dushanbe, Tajikistan. The airplane made a low pass over the field so the air traffic controllers could observe the nature of the damage. A forced landing was then carried out.
Probable cause:
The following findings were identified:
- Disturbance in the work of the command-supervisory composition of the "Airline Transport Incorporation" company, that led to the failure to present the crew with AIP information of the Republic of Afghanistan about the Kabul Airport minima and the special features of the approach to this airport, as presented in the "Jeppesen", valid on 30.12.04;
- Decision making by crew and the decision to carry out an approach under below-minima conditions; unsatisfactory crew interaction during the final stage of the approach, which led to the loss of height, the failure to retract the spoilers, the descent below the established glide path, the collision of aircraft with a ground-based structure and the late spool-up of the engines to takeoff power;
- Deficiencies in the weather support of the flight, in that the crew were not given a visibility forecast, which did not allow crew to estimate the level of hazard of a change in the meteorological conditions.

Crash of a Piper PA-31P Pressurized Navajo in Gallup: 1 killed

Date & Time: Dec 29, 2004 at 1018 LT
Type of aircraft:
Registration:
N573B
Flight Type:
Survivors:
No
Schedule:
Glendale – Newton
MSN:
31-7530008
YOM:
1975
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
936
Captain / Total hours on type:
62.00
Aircraft flight hours:
6773
Circumstances:
While maneuvering during a precautionary landing with the right engine shutdown, the airplane entered a Vmc roll and an uncontrolled descent, and impacted wires, trees, and terrain. According to air traffic control communications, while en route the pilot experienced a rough running right engine and performed a precautionary shutdown of the engine. The pilot elected to divert to an airport and received vectors from air traffic control for a visual approach. Witnesses who were located at the airport reported the airplane was on a normal downwind for the runway. When the airplane reached the approach end of the runway, the pilot turned to the right which was away from the airport. A witness who was monitoring the UNICOM frequency informed the pilot he was turning away from the airport and the pilot responded, "Busy." The airplane continued the right turn subsequently entered a Vmc roll and a rapid descent toward the terrain. The airplane wreckage was located on hilly, rocky terrain approximately 3 miles south of the airport. The airplane was fragmented and destroyed during the impact sequence and post-impact fire. Examination of the airframe and propellers revealed no anomalies that would have precluded normal operations. Examination of the left engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. Examination of the right engine revealed the forward gearbox was destroyed and mechanical continuity of the rotating components and internal mechanisms was established. The reason for the reported rough running engine was not determined. The lifters installed in both engines during the overhauls were not approved lifters for the accident engines.
Probable cause:
The pilot's failure to maintain minimum controllable airspeed which resulted in the loss of control, and impact with wires, a tree and terrain.
Final Report:

Crash of a Lockheed MC-130H Hercules at Qayyarah Airfield West AFB

Date & Time: Dec 29, 2004
Type of aircraft:
Operator:
Registration:
85-0012
Flight Type:
Survivors:
Yes
MSN:
5054
YOM:
1985
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The MC-130H Hercules plane was on a nighttime logistics transport mission in support of Operation Iraqi Freedom. US operated airfield in northern Iraq, reportedly Qayyarah Airfield West, a trench was being dug in the runway 33. The construction works, approx. 2700 feet from the southern end of the runway were not marked nor NOTAMed. On landing, at a speed of 80 knots, the Hercules plane ran into the construction works. The nose gear and forward undercarriage were sheared off and the left wing separated just outside the no. 2 engine. The aircraft then caught fire. The crew members egressed safely, but the four passengers required assistance from ground personnel and aircrew.
Probable cause:
The Board President determined the causes of the accident are:
1) A failure on the part of the mishap site Assistant S-3 (Battle Captain[s]) to disseminate timely Notices to Airmen (NOTAM) information via the appropriate channels,
2) the failure of the Army project manager for construction at the mishap site to ensure the construction was properly marked and
3) a failure of the NOTAM reporting system to include oversight and supervision of the NOTAM processes, within the area of responsibility (AOR).
Contributing factors in this mishap include:
1) a lack of training on the part of the U.S. Army to effectively prepare their personnel for combat zone airfield management and operations, and
2) the failure of the Garrison Commander at the mishap location to assume responsibility for ensuring safe flight operations at the airfield.
The Board President also determined there were numerous opportunities for airfield construction information to flow to the aircrew, but in each case the information was not properly disseminated prior to the aircrew departing for their scheduled mission.

Crash of a Beechcraft A90 King Air in Montpellier: 3 killed

Date & Time: Dec 24, 2004 at 0933 LT
Type of aircraft:
Operator:
Registration:
F-GVRM
Flight Type:
Survivors:
No
Schedule:
Montpellier - Montpellier
MSN:
LJ-121
YOM:
1966
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
12184
Captain / Total hours on type:
2610.00
Copilot / Total flying hours:
256
Copilot / Total hours on type:
6
Aircraft flight hours:
6872
Aircraft flight cycles:
6816
Circumstances:
The crew departed Montpellier-Méditerranée Airport at 0802LT for a local training flight with TRI, one TRE and one pilot under supervision. Following a touch and go on runway 31R, the instructor decided to reduce the power on the right engine and to perform a low pass over the runway. Then the aircraft turned to the left, lost height, rolled to the left and crashed in a pond located to the right of the runway. The aircraft was destroyed and all three occupants were killed.
Probable cause:
The accident was the result of the crew losing control of the aircraft after a go-around. It is likely that this was the result of inadequate management of the flight controls while performing a one engine go-around and a too late a reaction from the examiner (TRE). The examiner's recent lack of experience in instruction on BE90 and his right-front position may have contributed to the accident. No technical anomalies was found on the aircraft and the loss of control occurred at low altitude.
Final Report:

Crash of a Partenavia P.68 off Puerto Villamil: 2 killed

Date & Time: Dec 21, 2004 at 1219 LT
Type of aircraft:
Operator:
Survivors:
No
Schedule:
Baltra Island - Puerto Villamil
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The twin engine aircraft departed Galapagos International Airport (Baltra Island) at 1200LT on a flight to Puerto Villamil Airport, Isabela Island, carrying one passenger and one pilot. At 1219LT, the pilot was cleared to descend to Puerto Villamil Airport when he lost control of the airplane that crashed in the sea. The wreckage was found few hundred metres offshore at 1655LT. Both occupants were killed. The accident occurred three minutes prior to landing.

Crash of a Piper PA-61P Aerostar (Ted Smith 601) in Wheeling

Date & Time: Dec 18, 2004 at 2215 LT
Operator:
Registration:
N60CF
Flight Type:
Survivors:
Yes
MSN:
61-0415-149
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot attempted a night landing on a taxiway in front of the control tower, which was closed at the time. The airplane overran the end of the taxiway, rolled down an embankment and struck trees. The pilot, whose identity was not confirmed, was believed to have incurred minor injuries. He subsequently paid a passerby to take him to a local hotel, and after a night's rest, he left the area. Ownership of the airplane could not be determined due to a recent sale. Approximately 250 kilos of cocaine were found onboard the airplane. Further investigation was being conducted by federal authorities and local law enforcement.
Probable cause:
The pilot misjudged his distance/speed, and his intentional landing on an unsuitable taxiway
at night. A factor in the accident was the night light conditions.
Final Report:

Crash of a Short 360-300 in Oshawa

Date & Time: Dec 16, 2004 at 2001 LT
Type of aircraft:
Operator:
Registration:
N748CC
Flight Type:
Survivors:
Yes
Schedule:
Toledo – Oshawa
MSN:
3748
YOM:
1988
Flight number:
SNC2917
Location:
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5300
Captain / Total hours on type:
1000.00
Copilot / Total flying hours:
800
Copilot / Total hours on type:
400
Circumstances:
Air Cargo Carriers, Inc. Flight SNC2917, a Short Brothers SD3-60 aircraft (registration N748CC, serial number SH3748), was on a charter cargo flight from Toledo, Ohio, USA, to Oshawa, Ontario, with two pilots on board. The crew conducted an instrument flight rules approach to Oshawa Municipal Airport in night instrument meteorological conditions. At approximately 2000 eastern standard time, the aircraft landed on Runway 30, which was snow-covered. During the landing roll, the pilot flying noted poor braking action and observed the runway end lights approaching. He rejected the landing and conducted a go-around procedure. The aircraft became airborne, but it started to descend as it flew over lower terrain, striking an airport boundary fence. It continued until it struck rising terrain and then a line of forestation, where it came to an abrupt stop. The flight crew exited the aircraft and waited for rescue personnel to render assistance. The aircraft was substantially damaged, and both pilots sustained serious injuries. There was no post-crash fire.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The crew planned and executed a landing on a runway that did not provide the required landing distance.
2. The flight crew most likely did not reference the Aircraft Flight Manual performance chart “Effect of a Slippery Surface on Landing Distance Required” to determine that landing the aircraft on the 4000-foot, snow-covered runway with flap-15 was inappropriate.
3. After landing long on the snow-covered runway and applying full reverse thrust, the captain attempted a go-around. He rotated the aircraft to a take-off attitude and the aircraft became airborne in ground effect at a slower-than-normal speed.
4. The aircraft had insufficient power and airspeed to climb and remained in ground effect until striking the airport perimeter fence, rising terrain, and a line of large cedar trees.
5. The flight crew conducted a flap-15 approach, based on company advice in accordance with an All Operator Message (AOM) issued by the aircraft manufacturer to not use flap-30. This AOM was superseded on 20 October 2004 by AOM No. SD006/04, which cancelled any potential flap-setting prohibition.
Other Finding:
1. The flight crew members were not advised that the potential Airworthiness Directive announced in the original AOM was not going into effect and that the use of flap-30 was acceptable, as relayed in the follow-up AOM.
Final Report: