Crash of an Aérospatiale SE-210 Caravelle 11R in Gisenyi

Date & Time: Aug 27, 2004
Operator:
Registration:
3D-KIK
Flight Type:
Survivors:
Yes
Schedule:
Kinshasa - Goma
MSN:
251
YOM:
1968
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft departed Kinshasa-N'Djili Airport on a cargo flight to Goma, carrying five passengers, three crew members and a load consisting of telecommunications equipment for the Company Celtel. While approaching Goma, the crew was informed by ATC about the deterioration of the weather conditions at destination and a landing was not possible. Following a holding circuit, the crew was low on fuel and decided to divert to Gisenyi Airport, Rwanda. After landing on runway 01/19 which is 1,000 metres long, the aircraft went out of control, veered off runway and came to rest, bursting into flames. All eight occupants escaped uninjured while the aircraft was destroyed by fire.

Crash of a Convair CV-580 in Cincinnati: 1 killed

Date & Time: Aug 13, 2004 at 0049 LT
Type of aircraft:
Operator:
Registration:
N586P
Flight Type:
Survivors:
Yes
Schedule:
Memphis - Cincinnati
MSN:
68
YOM:
1953
Flight number:
HMA185
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2500
Captain / Total hours on type:
1337.00
Copilot / Total flying hours:
924
Copilot / Total hours on type:
145
Aircraft flight hours:
67886
Circumstances:
On August 13, 2004, about 0049 eastern daylight time, Air Tahoma, Inc., flight 185, a Convair 580, N586P, crashed about 1 mile south of Cincinnati/Northern Kentucky International Airport (CVG), Covington, Kentucky, while on approach to runway 36R. The first officer was killed, and the captain received minor injuries. The airplane was destroyed by impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a cargo flight for DHL Express from Memphis International Airport (MEM), Memphis, Tennessee, to CVG. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight crew was scheduled to fly the accident airplane on a roundtrip sequence from MEM to CVG. Flight 185 departed MEM about 2329. The first officer was the flying pilot, and the captain performed the non flying pilot duties. During postaccident interviews, the captain stated that the takeoff and climb portions of the flight were normal. According to the cockpit voice recorder (CVR) transcript, at 0017:49, the captain stated that he was just going to “balance out the fuel here.” The first officer acknowledged. From 0026:30 to 0027:08, the CVR recorded the captain discussing the airplane’s weight and balance with the first officer. Specifically, the captain stated, “couldn’t figure out why on the landing I was out and I was okay on the takeoff.” The captain added, “the momentum is one six six seven and I…put one zero six seven and I couldn’t work it.” He then stated, “so…we were okay all along.” At 0030:40, the first officer stated, “weird.” At 0032:31, the captain stated, “okay just let me finish this [the weight and balance paperwork] off and…I’m happy,” and, about 2 minutes later, he stated, “okay, back with you here.” At 0037:08, the captain contacted Cincinnati Terminal Radar Approach Control (TRACON) and reported an altitude of 11,000 feet mean sea level. About 1 minute later, the first officer stated, “something’s messed up with this thing,” and, at 0039:07, he asked “why is this thing?” At 0041:21, the first officer stated that the control wheel felt “funny.” He added, “feels like I need a lot of force. it is pushing to the right for some reason. I don’t know why…I don’t know what’s going on.” The first officer then repeated twice that it felt like he needed “a lot of force.” The CVR did not record the captain responding to any of these comments. At 0043:53, when the airplane was at an altitude of about 4,000 feet, the captain reported to Cincinnati TRACON that he had the runway in sight. The approach controller cleared flight 185 for a visual approach to runway 36R and added, “keep your speed up.” The captain acknowledged the clearance and the instruction. The first officer then stated, “what in the world is going on with this plane? sucker is acting so funny.” The captain replied, “we’ll do a full control check on the ground.” At 0044:43, the approach controller again told the captain to “keep your speed up” and instructed him to contact the CVG Air Traffic Control Tower (ATCT). At 0045:11, the captain contacted the CVG ATCT and requested clearance to land on runway 36R, and the local control west controller issued the landing clearance. Flight data recorder (FDR) data indicated that, shortly afterward, the airplane passed through about 3,200 feet, and its airspeed began to decrease from about 240 knots indicated airspeed. At 0045:37, when the airplane was at an altitude of about 3,000 feet, the captain started the in-range checklist, stating, “bypass is down. hydraulic pressure. quantity checks. AC [alternating current] pump is on. green light. fuel panel. boost pumps on.” About 0046, the first officer stated, “I’m telling you, what is wrong with this plane? it is really funny. I got something all messed up here.” The captain replied, “yeah.” The first officer then asked, “can you feel it? it’s like swinging back and forth.” The captain replied, “we’ve got an imbalance on this…crossfeed I left open.” The first officer responded, “oh, is that what it is?” A few seconds later, the first officer stated, “we’re gonna flame out.” The captain responded, “I got the crossfeed open. just keep power on.” At 0046:45, the CVR recorded a sound similar to decreasing engine rpm. Immediately thereafter, the first officer stated, “we’re losing power.” At 0046:52, the first officer stated, “we’ve lost both of them. did we?” The captain responded, “nope.” FDR data showed that, about 1 second later, a momentary electrical power interruption occurred when the airplane was at an altitude of about 2,400 feet. At 0046:55, the CVR stopped recording. Airplane performance calculations indicated that, shortly after the power interruption, the airplane’s descent rate was about 900 feet per minute (fpm). According to air traffic control (ATC) transcripts, at 0047:12, the captain reported to the CVG ATCT that the airplane was “having engine problems.” The local control west controller asked, “you’re having engine problems?” The captain replied, “affirmative.” At 0047:28, the controller asked the captain if he needed emergency equipment, and the captain replied, “negative.’” This was the last transmission received by ATC from the accident flight crew. The FDR continued recording until about 0049. The wreckage was located about 1.2 miles short of runway 36R.
Probable cause:
Fuel starvation resulting from the captain’s decision not to follow approved fuel crossfeed procedures. Contributing to the accident were the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist. Further contributing to the accident was the flight crew’s failure to monitor the fuel gauges and to recognize that the airplane’s changing handling characteristics were caused by a fuel imbalance.
Final Report:

Crash of a Casa 212 Aviocar 200 in San Carlos de Rio Negro

Date & Time: Aug 5, 2004 at 1648 LT
Type of aircraft:
Operator:
Registration:
ARBV-0206
Flight Type:
Survivors:
Yes
Schedule:
Puerto Ayacucho - San Carlos de Rio Negro
MSN:
183
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to San Carlos de Rio Negro Airport was completed in stormy weather. After touchdown, the twin engine aircraft failed to stop within the remaining distance. It overran, went down an embankment, collided with a fence and came to rest along a dirt road. A passenger was slightly injured while 11 other occupants escaped unhurt. The aircraft was damaged beyond repair.

Crash of a PZL-Mielec AN-28 in Beni

Date & Time: Jul 29, 2004
Type of aircraft:
Registration:
ES-ELI
Flight Type:
Survivors:
Yes
MSN:
1AJ002-06
YOM:
1985
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft crashed upon landing, lost its right and came to rest. There were apparently no casualties.

Crash of a Rockwell Sabreliner 60 in Mexicali

Date & Time: Jul 28, 2004 at 1330 LT
Type of aircraft:
Operator:
Registration:
XC-PFN
Flight Type:
Survivors:
Yes
Schedule:
Tijuana – Mexicali
MSN:
306-111
YOM:
1976
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Tijuana, the aircraft landed too far down the runway 28 at Mexicali-General Rodolfo Sanchez Taboada Airport. Unable to stop within the remaining distance, it overran, rolled for about 750 metres, collided with an embankment and came to rest in a sandy area. All six occupants escaped uninjured while the aircraft was damaged beyond repair. The aircraft had the dual registration XC-PFN (civil) and PF-213 (military).

Crash of a Piper PA-31T Cheyenne II near Benalla: 6 killed

Date & Time: Jul 28, 2004 at 1048 LT
Type of aircraft:
Registration:
VH-TNP
Survivors:
No
Site:
Schedule:
Bankstown – Benalla
MSN:
31-7920026
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
14017
Captain / Total hours on type:
3100.00
Aircraft flight hours:
5496
Circumstances:
At 0906 Eastern Standard Time on 28 July 2004, a Piper Aircraft Corporation PA31T Cheyenne aircraft, registered VH-TNP, with one pilot and five passengers, departed Bankstown, New South Wales on a private, instrument flight rules (IFR) flight to Benalla, Victoria. Instrument meteorological conditions at the destination necessitated an instrument approach and the pilot reported commencing a Global Positioning System (GPS) non-precision approach (NPA) to Benalla. When the pilot had not reported landing at Benalla as expected, a search for the aircraft was commenced. Late that afternoon the crew of a search helicopter located the burning wreckage on the eastern slope of a tree covered ridge, approximately 34 km southeast of Benalla. All occupants were fatally injured and the aircraft was destroyed by impact forces and a post-impact fire.
Probable cause:
Significant factors:
1. The pilot was not aware that the aircraft had diverged from the intended track.
2. The route flown did not pass over any ground-based navigation aids.
3. The sector controller did not advise the pilot of the divergence from the cleared track.
4. The sector controller twice cancelled the route adherence monitoring alerts without confirming the pilot’s tracking intentions.
5. Cloud precluded the pilot from detecting, by external visual cues, that the aircraft was not flying the intended track.
6. The pilot commenced the approach at an incorrect location.
7. The aircraft’s radio altimeter did not provide the pilot with an adequate defence to avoid collision with terrain.
8. The aircraft was not fitted with a terrain awareness warning system (TAWS).
Final Report:

Crash of a Beechcraft 350 Super King Air in Punto Fijo

Date & Time: Jul 24, 2004
Operator:
Registration:
YV-910CP
Flight Type:
Survivors:
Yes
Schedule:
La Carlota - Calabozo - Punto Fijo
MSN:
FL-206
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft completed a charter flight from La Carlota to Calabozo with four passengers and two pilots. At Calabozo Airport, the four passengers brandished guns and took over the airplane on an illegal flight to Punto Fijo. Upon arrival, the aircraft crashed under unknown circumstances. There were no casualties and the aircraft was destroyed.

Crash of a Basler BT-67 in El Jaguey

Date & Time: Jul 23, 2004 at 0930 LT
Type of aircraft:
Operator:
Registration:
FAS117
Flight Type:
Survivors:
Yes
MSN:
24509
YOM:
1944
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at El Jaguey Airstrip, the aircraft suffered a hydraulic failure and became uncontrollable. It veered off runway, lost its undercarriage and came to rest few dozen metres further. All 24 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Learjet 55 Longhorn in Fort Lauderdale

Date & Time: Jul 19, 2004 at 1137 LT
Type of aircraft:
Operator:
Registration:
N55LF
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Fort Lauderdale
MSN:
55-112
YOM:
1984
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7595
Captain / Total hours on type:
1994.00
Copilot / Total flying hours:
412
Copilot / Total hours on type:
10
Aircraft flight hours:
6318
Circumstances:
The flight was a VFR positioning flight from FLL to FXE. Transcripts of the cockpit voice recorder (CVR) showed that while waiting for takeoff from FLL the flightcrew heard the local controller reported to a Delta Airlines flight that was on a seven mile final approach to land on runway 27R that the winds were 250 degrees at 19 knots, gusting to 50 knots. The Delta Airlines flight crew then informed the controller they were making a missed approach. At 1130:05 the captain asks the first officer if "can you see the end of the weather? If we make a hard right turn, can we stay clear of it?" The first officer responded "I believe so." At 1130:06 the local controller reported "wind shear alert. The centerfield wind 230 at 22. Runway 27R departure 25 knot loss one mile departure." The captain stated to the first officer "sweet." At 1132:11 the captain transmitted to the local controller "tower, any chance of Hop-a-Jet 55 getting out of here?" The local controller responded wind 230 at 17, right turn direct FXE approved, runway 27R cleared for takeoff. The captain responded "cleared to go, right turn out." At 1133:10 the captain asks for gear up. At 1133:15 the local controller responded to a Southwest Airlines Flight waiting for takeoff "no, don't look like anyone's gonna go." "The uh, weather is due west moving rapidly to the north. It looks like a few minutes, and you all be in the clear straight out." At 1133:17, the captain stated to the first officer "oh #. Think this was a bad idea." The first officer responded "no airport in sight." At 1133:43 the sound similar to precipitation hitting the windshield is recorded. At 1133:46 the FLL local controller instructs the flight crew to contact FXE Tower. At 1133:54 the CVR records the FXE local controller transmitting "wind 200, variable 250 at 15, altimeter 29.99. Heavy cell of weather to the west moving eastbound. Low level wind shear possible. At 1134:16, the FXE local controller transmits "attention all aircraft, low level wind shear advisories are in effect. Use caution. Wind 240 at 10." At 1134:51, the first officer transmitted to the FXE local controller that the flight was over the shoreline inbound full stop. At 1135:02, the FXE local controller transmitted "Hop-a-Jet 55, Executive tower, wind 210 variable 250 at 35, 35 knots and gusting. Winds are uh, heavy on the field. Low level wind shear advisories are in effect. Heavy rains from the west, eastbound and would you like to proceed inbound and land Executive? Say intentions." The first officer responded "that's affirmative." The local controller responded, "Hop-a-Jet 55 straight in runway three one if able. The winds 230 gusts, correction, winds 230 variable 210 at 25." At 1135:48, the local controller transmitted, "Hop-a-Jet 55, wind 230 variable 300 at 25 gusts 35. Altimeter 30.00. Runways are wet. Traffic is exiting the runway prior to your arrival, a Dutchess. Caution standing water on runways. Low level wind shear advisories in effect, Runway 31. Cleared to land." The first officer responded "cleared to land, Hop-a-Jet 55." At 1136:35, the local controller transmitted "wind 230 at 25, gusts 35." At 1136:58, the CVR records the sound similar to precipitation on the windshield. At 1137:17, the CVR records a sound similar to the aircraft touching down on the runway. At 1137:19, the sound of a repetitive tone similar to the thrust reverser warning starts and continues to the end of the recording. At 1137:23 a loud unidentified roaring sound starts and lasts 8 seconds. At 1137:30, loud rumbling noises similar to the aircraft departing the runway start. At 1137:36, a continuous tone similar to landing gear warning signal sounds and continues to the end of the recording. The rumbling noises stop. At 1137:39 the captain states the thrust reversers didn't stow and at 1138:36, the captain states "I went around and the # TRs stayed. The CVR recording ended. The 1132, Goes-12 infrared image depicts a rapidly developing cumulonimbus cloud between and over the FLL and FXE airports. The top of the cloud over FXE was in the range of 22,000 feet. The top of the cloud southwest of FXE was in the 39,000 feet range. The 1145, Goes-12 infrared image depicts a developing cumulonimbus cloud over FXE with the cloud top in the 42,000 feet range. Data was obtained from the Melbourne, Florida Doppler Weather Radar System, located 118 miles north-northwest of the accident site. The data showed that at FXE, between 1130 and 1145, a VIP Level 1 to 2 echo evolved into a VIP Level 5 "intense" echo at 1135 and a VIP Level 6 "extreme" echo by 1145.
Probable cause:
The flight crew's decision to continue the approach into known area of potentially severe weather (Thunderstorm), which resulted in the flight encountering a 30 knot crosswind, heavy rain, low-level wind shear, and hydroplaning on a ungrooved contaminated runway.
Final Report:

Crash of a PZL-Mielec AN-28 in Østre Æra

Date & Time: Jul 16, 2004 at 1324 LT
Type of aircraft:
Registration:
YL-KAB
Survivors:
Yes
Schedule:
Østre Æra - Østre Æra
MSN:
1AJ009-15
YOM:
1991
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14000
Captain / Total hours on type:
400.00
Copilot / Total flying hours:
18000
Copilot / Total hours on type:
1000
Circumstances:
Two aircraft of type AN-28, operated by Rigas Aeroklubs Latvia, were dropping parachutists at the National Parachute Sport Centre, Østre Æra airstrip in Østerdalen. The company had had a great deal of experience with this type of operations, and had been carrying out parachute drops in Norway each summer for the last 9 years. They had brought their own licensed aircraft technicians with them to Østre Æra. On Friday morning, 16 July 2004, the weather conditions were good when the flights started. The crew of YL-KAB, which comprised two experienced pilots, were rested after a normal night's sleep. They first performed six routine drop flights. After stopping to fill up with fuel, normal preparations were made for the next flight with 20 parachutists who were to jump in two groups of 10. The seventh departure was carried out at time 1305. The Commander asked for and was given clearance by the air traffic control service to climb to flight level FL150 (15,000 ft equivalent to approx. 4,500 metres). The parachutists were then dropped from that altitude. The first drop of 10 parachutists was made on a southerly course above the airstrip, and the aircraft continued on that course for a short time before turning through 180° and getting ready for the next drop at the same location on a northerly course. A large cumulonimbus cloud (CB), with precipitation, had approached the airfield from the north at this time. To reach the drop zone above the runway, the aircraft had to fly close to this cloud. The aircraft was not equipped with weather radar. The last parachutists to leave the aircraft were in a tandem jump that was being filmed on video. The film showed that the parachutists became covered in a layer of white ice within 2-3 seconds of leaving the aircraft. The ice on the parachutists only thawed once they had descended to lower altitudes where the air temperature was above zero. Once the parachutists had jumped, the aircraft was positioned close to the CB cloud at a low cruising speed. They were exposed to moderate turbulence from the cloud. The Commander, who was the PF (pilot flying), started a sudden 90° turn to the left while also reducing engine power to flight idle in order to avoid the CB cloud and return to Østre Æra to land. At this point, the First Officer who was PNF (pilot not flying) observed that ice had formed on the front windshield, and he chose to switch on the anti-icing system. He did this without informing the PF. A few seconds later both engines stopped, and both propellers automatically adopted the feathered position. The pilots had not noticed any technical problems with the aircraft engines before they failed. During the descent, the PNF, on the PF's orders, carried out a series of start-up attempts with reference to the checklist/procedure they had available in the cockpit. The engines would not start and the PF made a decision and prepared to carry out an emergency landing at Østre Æra without engines. The runway at Østre Æra is 600 m long and 10 m wide. The surrounding area is covered by dense coniferous forest and they had no alternative landing areas within reach. Because they were without engine power, there was no hydraulic power to operate the aircraft's flaps. This meant that the speed of the aircraft had to be kept relatively high, approx. 160-180 km/h. The final approach was further complicated because the PF had to avoid the last 10 parachutists who were still in the air and who were steering towards a landing area just beside the airstrip. The PF first positioned the aircraft on downwind on a southerly course west of the airfield, in order then to make a left turn to final on runway 01. The landing took place around halfway down the runway, at a faster speed than normal - according to the Commander's explanation approximately 160-170 km/h. The PF braked using the wheel brakes, but when he realized that he would not be able to stop on the length of runway remaining, he ceased braking. He knew that the terrain directly on the extension to the runway was rough, and chose to use the aircraft's remaining speed to lift it off the ground and to alter course a little to the right. The aircraft passed over the approx. 2.5 m high embankment in the transition between the runway level and the higher marshy plateau surrounding the northern runway area, see Figure 1. The aircraft ran approx. 230 m in ground effect before landing on its heels in the flat marshy area north of the airfield. After around 60 m of roll-out, the nose wheel and the aircraft's nose struck a ditch and the aircraft turned over lengthways. It came to rest upside down with its nose section pointing towards the landing strip.
Probable cause:
The experienced Commander assessed the distance to the cumulonimbus cloud as sufficient to allow the drop to be carried out, and expected that they would then rapidly make their way out of the exposed area. It appeared, however, that problems arose when the aircraft was exposed to turbulence and icing from the cloud. The AIBN believes the limits of the engines' operational range were exceeded since the anti-icing system was switched on while the power output from the engines was low, in combination with low airspeed, turbulence and sudden manoeuvring. At that, both engines stopped, and the propellers were automatically feathered. The AIBN believes the engines would not restart because the Feathering Levers were not moved from the forward to the rear position and forward again, as is required after automatic feathering. The manufacturer has pointed out that, according to the procedures, the crew should have refrained from restart attempts and prioritized preparing for the emergency landing. AIBN acknowledges this view, taken into consideration that the crew had not received necessary training and that no suitable checklists existed. On the other hand, it is the AIBN’s opinion that this strategy may appear too passive in a real emergency. If the flight is over rugged mountain terrain or over water, an emergency landing may have fatal outcome. Provided there is sufficient time, and that crew cooperation is organised in such a way that it does not jeopardise the conduct of safe flight, a successful restart may prevent an accident. The AIBN cannot rule out the possibility that the crew's ability to make a correct assessment of the situation was reduced due to oxygen deficiency. Low oxygen-saturation in the brain would first lead to generally reduced mental capacity. In particular, this applies to the capacity to do several things simultaneously and the ability to remember. These are factors that are crucial when a pilot in a stressful situation has to choose the best solution to a problem, and the negative effects will appear more rapidly the older a person is. The fact that the First Officer switched on the anti-icing system without asking the Commander first, indicates that crew collaboration was not functioning at its best. The AIBN believes that the crew, after having entered this difficult situation, carried out a satisfactory emergency landing under very demanding conditions. The fact of the parachutists being within the approach sector made the scenario more complex, and a landing ahead of the threshold had to be avoided. With the flaps non-functional, it is understandable that the speed was high and the touchdown point not optimal. The fact that the Commander got the aircraft into the air again and landed on the higher marshy plateau, was probably crucial to the outcome. Continued braking would have resulted in the aircraft running into the earth embankment at relatively high residual speed, and it is doubtful whether the crew would have survived. A safety recommendation is being put forward in connection with this. Even if allowances are made for parachuting being a special type of operation that often takes place under the direction of a club, the AIBN believes that this investigation has uncovered several issues that cannot be considered to be satisfactory when compared to the safety standard on which they ought to be based. A user-friendly checklist system in the cockpit which is used during normal operations, in emergency situations and during flight training would increase the probability of the aircraft being operated in accordance with the manufacturer's recommendations. It is of great importance that pilots are sufficiently trained and experienced to carry out appropriate emergency procedures. It is assumed, however, that the new regulation concerning civil parachute jumping will contribute to increased levels of safety, and the AIBN sees no need to recommend any further measures.
Final Report: