Crash of a Douglas DC-3C in Medellín: 3 killed

Date & Time: Oct 15, 2004 at 0750 LT
Type of aircraft:
Operator:
Registration:
HK-1503
Flight Type:
Survivors:
No
Site:
Schedule:
Villavicencio - Medellín
MSN:
17064/34331
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
21490
Captain / Total hours on type:
370.00
Copilot / Total flying hours:
305
Copilot / Total hours on type:
91
Aircraft flight hours:
27592
Circumstances:
The aircraft departed Villavicencio on a cargo flight to Medellin-José María Córdova Airport with one passenger and two pilots on board. While descending to Medellín, the crew was informed about the poor weather conditions at destination (poor visibility due to fog) and decided to divert to Medellín-Enrique Olaya Herrera Airport. On final approach, the aircraft descended too low when it struck a mountain located 13 km short of runway. The aircraft was destroyed and all three occupants were killed.
Probable cause:
Controlled flight into terrain after the crew took the decision to continue the approach under VFR mode in IMC conditions until the aircraft impacted terrain. Poor CRM and lack of situational awareness were considered as contributing factors.
Final Report:

Crash of a Piper PA-46-310P Malibu in Corcelles-les-Monts: 4 killed

Date & Time: Oct 9, 2004 at 1418 LT
Registration:
N20VP
Flight Type:
Survivors:
No
Site:
Schedule:
Ostend - La Chassagne
MSN:
46-8408062
YOM:
1984
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
2958
Captain / Total hours on type:
300.00
Circumstances:
The single engine aircraft departed Ostend Airport, Belgium, on a flight to the private airstrip of Château La Chassagne located about 21 km west of the Dijon-Longvic Airport. The flight from Ostend to Dijon was completed under IFR rules and was uneventful. After being cleared to continue under VFR to La Chassagne, the pilot cancelled the IFR flight plan and was cleared for a descent to runway 36. Visibility was 10 km, rain, ceiling at 800 feet and minimum safe altitude at 3,300 feet. The pilot informed ATC he was descending to runway 18 and left the frequency. Shortly later, at an altitude of 1,700 feet, the aircraft struck the southeast slope of Mt Afrique located in Corcelle-les-Monts. The wreckage was found in a wooded area and all four occupants were killed.
Probable cause:
The accident was the result of a controlled flight into terrain following the obstinacy of the pilot to continue the descent in adverse weather conditions. It was also reported that the medical certificate, related to the pilot's license issued by the United States in 2002, was obtained on the basis of a false declaration, omitting the elements that had previously justified unfitness in Belgium.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in Sylhet

Date & Time: Oct 8, 2004 at 0915 LT
Type of aircraft:
Operator:
Registration:
S2-ACH
Survivors:
Yes
Schedule:
Dhaka - Sylhet
MSN:
11172
YOM:
1981
Flight number:
BG601
Location:
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
79
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The flight from Dhaka to Sylhet was delayed for few hours due to poor weather conditions at destination with limited visibility, heavy rain falls, low ceiling and strong winds. Following an uneventful flight, the aircraft landed too far down a wet runway. Unable to stop within the remaining distance, it overran and came to rest in a drainage ditch. 30 passengers were slightly injured while all other occupants escaped unhurt. Both pilots were seriously injured as the cockpit was trapped against an earth wall.
Probable cause:
It was determined that the crew failed to refer to the PAPI's and following a wrong approach configuration, the aircraft landed too far down the runway, reducing the landing distance available. The following contributing factors were reported:
- The ILS system was not properly calibrated, causing the aircraft to land about 900 feet past the runway threshold,
- The aircraft was too high on approach,
- The aircraft' speed at touchdown was 20 knots above the reference speed,
- The braking action was considered as low because the runway surface was wet,
- Aquaplaning,
- The crew failed to initiate a go-around procedure.

Crash of a Cessna 207 Skywagon in Urimán

Date & Time: Oct 6, 2004
Operator:
Registration:
YV-217C
Survivors:
Yes
Site:
MSN:
207-0440
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On approach to Urimán, the single engine aircraft crashed in a wooded area located few km from the destination airport. Both occupants were rescued a day later. The passenger was injured and the pilot was unhurt.

Crash of a Cessna 208B Super Cargomaster in Gwinner

Date & Time: Sep 23, 2004 at 2345 LT
Type of aircraft:
Registration:
N7392B
Flight Type:
Survivors:
Yes
Schedule:
Fergus Falls – Gwinner
MSN:
208B-0045
YOM:
1987
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
17420
Captain / Total hours on type:
50.00
Aircraft flight hours:
11945
Circumstances:
The airplane was substantially damaged when it impacted an open field about 1-1/2 miles south of the destination airport. The pilot had executed an instrument approach and was circling to land when the accident occurred. Night instrument meteorological conditions prevailed at the time. The area south and east of the airport was sparsely populated. The pilot reported that he obtained the Automated Weather Observing System (AWOS) broadcast for the destination via the aircraft radio while en route. He stated the reported visibility was above that required for the Non-Directional Beacon (NDB) approach, however, the ceiling was below the minimum descent altitude (MDA). He reported that he attempted to contact air traffic control (ATC) with the intention of diverting. He was not able to contact ATC and elected to continue to the destination. The pilot reported that he flew the entire NDB approach and stated: "When I arrived at the MDA, I saw the runway, directly below and a little to my left. My plan, at the time, was to circle left and land." He stated after that point he had no further recollection of the events surrounding the accident. The pilot reported that there were no failures or malfunctions associated with the aircraft. Two witnesses reported seeing lights from an airplane near the airport. One recalled that the weather was "foggy and a heavy mist." The other witness stated: "When I saw the plane it was very low but I thought it was going around for the landing because it looked like the plane had its right wing higher, and I could see part of the belly of the plane, which made it look like it was banking around." Flight control continuity was confirmed during a post-accident examination. The airport AWOS recorded an overcast sky at 400 feet above ground level (agl). The MDA for the instrument approach as 694 feet above field elevation.
Probable cause:
The pilot's failure to maintain altitude during the circling maneuver. Contributing factors were the pilot's improper decision to execute the approach when weather conditions were below minimums and the low light (dark night) conditions.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Lakeway: 2 killed

Date & Time: Sep 23, 2004 at 1619 LT
Operator:
Registration:
N729DM
Flight Type:
Survivors:
Yes
Schedule:
Angel Fire – Austin
MSN:
421C-1101
YOM:
1981
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
14000
Captain / Total hours on type:
9.00
Aircraft flight hours:
5328
Circumstances:
The 14,000-hour airline transport pilot was hired to fly the owner of the airplane and his mother on a cross country flight. Approximately 3 hours and 15 minutes into the flight, the pilot reported that he had a rough running engine and declared an emergency. A review of ATC voice communications revealed that the pilot had changed his mind several times during the emergency about diverting to a closer airport or continuing to the intended destination. Prior to his last communication, the pilot informed ATC that he, "was not gonna make it." The sole survivor of the accident reported that the flight was normal until they approached their destination. He said, "all of a sudden the engines did not sound right." The right engine sounded as if the power was going up and down and the left engine was sputtering. The airplane started to descended and the pilot made a forced landing in wooded area. The cockpit, fuselage, empennage, and the right wing were consumed by post-impact fire. A review of fueling records revealed that the pilot had filled the main tanks prior to the flight for a total of 213.4 gallons; of which 206 gallons were usable (103 gallons per side). During the impact sequence, the left wing separated at the wing root and did not sustain any fire damage. No fuel was found in the tank, and there was no discoloration of the vegetation along the left side of the wreckage path or around the area where the wing came to rest. The left fuel selector was found set to the LEFT MAIN tank, and the right fuel selector valve was set between the LEFT and RIGHT MAIN tanks. This configuration would have allowed fuel to be supplied from each tank to the right engine. A review of the airplane's Information Manual, Emergency Procedures Engine Failure During Flight (speed above air minimum control speed) instructed the pilot to re-start the engine, which included placing both fuel selector handles to the MAIN tanks (Feel for Detent). If the engine did not start, the pilot was to secure the engine, which included closing the throttle and feathering the propeller. The propellers were not feathered. Examination of the airplane and engine revealed no mechanical deficiencies.
Probable cause:
The pilot's improper positioning of the fuel selector valves, which resulted in a loss of power to the left engine due to fuel exhaustion. After the power loss, the pilot failed to follow checklist procedures and did not secure (feather) the left propeller, which resulted in a loss of altitude and subsequent forced landing.
Final Report:

Crash of a Swearingen SA227AC Metro III in La Ronge

Date & Time: Sep 21, 2004 at 1410 LT
Type of aircraft:
Operator:
Registration:
C-FIPW
Survivors:
Yes
Schedule:
Stony Rapids - La Ronge
MSN:
AC-524
YOM:
1982
Flight number:
KA1501
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
A Northern Dene Airways Ltd. Metro III (registration C-FIPW, serial number AC524), operating as Norcanair Flight KA1051, departed Stony Rapids, Saskatchewan, with two crew members and nine passengers on a day, visual flight rules flight to La Ronge, Saskatchewan. On arrival in La Ronge, at approximately 1410 central standard time, the crew completed the approach and landing checklists and confirmed the gear-down indication. The aircraft was landed in a crosswind on Runway 18 and touched down firmly, approximately 1000 feet from the threshold. On touchdown, the left wing dropped and the propeller made contact with the runway. The aircraft veered to the left side of the runway, despite full rudder and aileron deflection. The crew applied maximum right braking and shut down both engines. The aircraft departed the runway and travelled approximately 200 feet through the infield before the nose and right main gear were torn rearwards; the left gear collapsed into the wheel well. The aircraft slid on its belly before coming to rest approximately 300 feet off the side of the runway. Three of the passengers suffered minor injuries from the sudden stop associated with the final collapsing of the landing gear; the other passengers and the pilots were not injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. An incorrect roller of a smaller diameter and type was installed on the left main landing gear outboard bellcrank assembly, contrary to company and industry practice.
2. The smaller diameter roller reduced the required rigging tolerances for the bellcrank-to-cam assembly in the down-and-locked position and allowed the roller to eventually move beyond the cam cutout position, resulting in the collapse of the left landing gear.
3. A rigging check was not carried out after the replacement of the bellcrank roller. Such a check should have revealed that neither the inboard nor outboard bellcrank assembly met the minimum rigging requirements for proper engagement with the positioning cam.
Final Report:

Crash of a Swearingen SA227AC Metro III in George

Date & Time: Sep 10, 2004 at 0545 LT
Type of aircraft:
Registration:
ZS-OLS
Flight Type:
Survivors:
Yes
Schedule:
Bloemfontein – George
MSN:
AC-748B
YOM:
1989
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2465
Captain / Total hours on type:
657.00
Aircraft flight hours:
8760
Circumstances:
The aircraft was on a Domestic Charter flight (IFR) from Bloemfontein Aerodrome to George Aerodrome when the crew elected to execute an ILS approach for landing onto Runway 11. At 1,000 feet from the threshold of Runway 11 with the undercarriage selected down and at full flaps for landing at an IAS of 120kt when he advised the copilot that was the flying pilot at the time, to continue visually with the approach for Runway 11. Shortly thereafter they heard a loud impact sound and the right hand engine failed. The aircraft suddenly yawed and banked severely to the right and the flying pilot commented that they had experienced a bird strike on the right hand engine. The pilot-in-command immediately took over the controls and attempted to arrest the yaw to the right but the aircraft kept yawing to the right. He then made a blind transmission on frequency 118.9 MHz and called for a go-around. The co-pilot then selected full power on both engines retracted the undercarriage, whilst the pilot-in-command feathered the right-hand propeller. According to the pilot-in-command, the aircraft continued to yaw to the right and with the stall aural warning sounding with a loss of altitude, he pulled the left-hand engine stop and feather control and was committed to execute a forced landing on a cattle farm The pilot-in-command stated that aircraft was approximately just outside the boundary fence. Both wings collided with the gum poles of a telephone and wire fence causing extensive damage to the wings and fuselage under-surface. Both occupants sustained no injuries.
Probable cause:
The aircraft encountered a bird strike on the right-hand engine prior to landing at George Aerodrome. It appears that the cockpit crew did not apply the correct procedures for a go-around when the aircraft yawed Severely to the right. The aircraft failed to climb and a forced landing was executed on a cattle farm.
Final Report:

Crash of a Rockwell Sabreliner 40R in Villahermosa: 2 killed

Date & Time: Sep 9, 2004 at 0650 LT
Type of aircraft:
Operator:
Registration:
XA-TFD
Flight Type:
Survivors:
No
Schedule:
Mexico City – Villahermosa
MSN:
265-13
YOM:
1960
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On approach to Villahermosa-Capitán Carlos Rovirosa Pérez Airport runway 26, the crew encountered poor visibility due to low clouds. As he was unable to locate the runway, the captain decided to initiate a go-around procedure. Few minutes later, while on a second attempt to land, the crew descended below the MDA until the aircraft impacted the ground and crashed near a wooded area located 3 km short of runway, bursting into flames. Both pilots were killed.
Probable cause:
Controlled flight into terrain after the crew descended below the MDA in poor visibility until the aircraft impacted terrain.

Crash of an Antonov AN-12B in Kiev

Date & Time: Sep 5, 2004 at 1000 LT
Type of aircraft:
Operator:
Registration:
UR-11765
Flight Type:
Survivors:
Yes
MSN:
4 017 05
YOM:
1964
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Kiev-Borispol Airport, the aircraft went out of control and veered off runway. The undercarriage collapsed and the aircraft came to rest. All five crew members escaped uninjured.