Crash of a PZL-Mielec AN-2R in Pavlovsk: 3 killed

Date & Time: Mar 24, 2004 at 2125 LT
Type of aircraft:
Operator:
Registration:
RA-33596
Survivors:
No
Schedule:
Pavlovsk - Pavlovsk
MSN:
1G230-38
YOM:
1988
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The single engine aircraft was dispatched in Pavlovsk with one technician and two pilots for a local crop spraying mission. While on a night approach to Pavlovsk Airfield, the crew failed to realize his altitude was too low. On final, both lower wings collided with trees (10 metres high). The aircraft rolled to the left to an angle of 45° then crashed 390 metres short of runway, bursting into flames. All three occupants were killed.
Probable cause:
It was determined that the crew departed Pavlovsk without prior permission so the flight was considered as illegal. The approach was completed by night to an airport that was not suitable for night operations as it was not equipped with approach and/or runway lights.

Crash of a Learjet 35A in Utica

Date & Time: Mar 19, 2004 at 0645 LT
Type of aircraft:
Operator:
Registration:
N800AW
Flight Type:
Survivors:
Yes
Schedule:
Columbus - Utica
MSN:
35-149
YOM:
1977
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5903
Captain / Total hours on type:
2036.00
Copilot / Total flying hours:
3956
Copilot / Total hours on type:
504
Aircraft flight hours:
15331
Circumstances:
The copilot was flying an ILS approach at an airspeed of Vref plus 10 knots, and the captain made visual contact with the runway about 350 feet agl. The airplane then drifted high on the glideslope, and the copilot decreased engine power. The sink rate subsequently became too great. By the time the captain called for a go-around, the airspeed had deteriorated, and the stick shaker activated. Although power was applied for the go-around, the airplane impacted the runway in a level attitude before the engines spooled up. The airplane came to rest in snow, about 20 feet off the left side of the runway, near mid-field.
Probable cause:
The copilot's failure to maintain airspeed, and the captain's delayed remedial action, which resulted in an inadvertent stall and the subsequent hard landing.
Final Report:

Crash of a Beechcraft 1900C near Tonopah: 5 killed

Date & Time: Mar 16, 2004 at 0401 LT
Type of aircraft:
Operator:
Registration:
N27RA
Flight Type:
Survivors:
No
Schedule:
Groom Lake - Tonopah
MSN:
UB-37
YOM:
1985
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The Air Force Materiel Command Beech 1900 crashed while on a routine support mission from a remote classified airstrip on the Nellis range to the Tonopah Test Range. It departed at 03:43 for Tonopah. After reporting the runway lights in sight, the pilot configured the airplane for the approach and initiated a circling maneuver to the right for a visual straight-in approach to runway 32. During the turn the pilot suffered a sudden cardiac death. Half way through the turn the airplane began a gradual descent until it impacted the ground. The airplane broke up and burst into flames. Investigation revealed that the pilot had violated federal policy and directives, wilfully deceived flight medical examiners, suppressed significant medical information and ingested inappropriate medications for a deteriorating and dangerous health condition. The pilot had high blood pressure and failed to report it, and denied taking medications to his Federal Aviation Administration flight physical examiners.
Probable cause:
The pilot became incapacitated during his approach to land due to sudden cardiac death.

Crash of a Mitsubishi MU-2B-40 Solitaire in Napa: 2 killed

Date & Time: Mar 11, 2004 at 2035 LT
Type of aircraft:
Registration:
N966MA
Flight Type:
Survivors:
No
Schedule:
Imperial – Napa
MSN:
405
YOM:
1979
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4546
Captain / Total hours on type:
1651.00
Aircraft flight hours:
4119
Circumstances:
The airplane entered a descending turn while on a night visual approach and impacted a river. At 2030, the pilot reported leaving 6,000 feet, and stated that he had the airport in sight. The controller cleared him for the approach. He advised the controller that he would like to cancel his IFR clearance, and switch to the traffic advisory frequency. The controller cleared him to switch to advisory frequency. No further transmissions were recorded from the flight. According to radar data, the airplane was southeast of the airport, and maintaining a westerly heading south of the airport. At 2035, it crossed a river, and began a sharp left turn away from the airport. It completed about 90 degrees of turn before abruptly disappearing from radar contact, with the last radar target on the west side of the river near the impact location. The highly fragmented wreckage was recovered from the river after several weeks underwater. The teardown and examination of the engines disclosed that the left engine was not rotating or operating at the time of impact, and the left propeller was in feather. The type and degree of damage to the right engine was indicative of engine rotation and operation at the time of impact. Investigators found no pre-existing condition on either engine, or with the airframe systems, that would have interfered with normal operation, or explained the apparent shutdown of the left engine.
Probable cause:
The pilot's failure to maintain control of the airplane following a shutdown of the left engine during a night visual approach. A factor contributing to the accident was the dark night.
Final Report:

Crash of a Cessna 560 Citation Encore at Miramar NAS: 4 killed

Date & Time: Mar 10, 2004 at 2042 LT
Type of aircraft:
Operator:
Registration:
165938
Flight Type:
Survivors:
No
Schedule:
Grand Junction - Miramar
MSN:
560-0567
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
The crew was returning to Miramar NAS following a routine training mission in Grand Junction. On final approach to Miramar NAS by night, the aircraft crashed near the interstate 15, about 2,400 metres short of runway 24R. The aircraft was destroyed and all four occupants were killed. A weather observation taken from the base at 2045LT reported five-mile visibility with light fog or haze, and a cloud ceiling at 800 feet.
Crew:
Lt Col T. Nicholson,
Lt Col Robert Zeisler.
Passengers:
Sgt Francisco Cortez,
Cpl Jeremy Lindroth.

Crash of a Canadair CL-415 off Les Salles-sur-Verdon: 2 killed

Date & Time: Mar 8, 2004 at 1100 LT
Type of aircraft:
Operator:
Registration:
F-ZBEZ
Flight Type:
Survivors:
Yes
Schedule:
Marseille - Marseille
MSN:
2018
YOM:
1996
Flight number:
Pélican 41
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
One instructor and two pilots under supervision departed Marseille-Marignane Airport on a training flight. Several scooping manoeuvres were completed on the Sainte-Croix Lake located about 85 km northeast of Marseille. While completing a new scooping procedure, the aircraft approached in a high nose attitude and disintegrated upon landing. The main wreckage sank to a depth of 31 metres off Les Salles-sur-Verdon. One pilot was found alive but seriously injured due to hypothermia (the water temperature was 6° C) while both other occupants, Jean Beauvais and Jean-Pierre Laty, were killed.

Crash of a Beechcraft 200 Super King Air in Berkovići: 9 killed

Date & Time: Feb 26, 2004 at 0745 LT
Registration:
Z3-BAB
Flight Type:
Survivors:
No
Site:
Schedule:
Skopje – Mostar
MSN:
BB-652
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
9
Circumstances:
The twin engine aircraft departed Skopje on an official flight to Mostar, carrying two pilots and seven passengers, among them Boris Trajkovski, President of the Republic of Macedonia. He was flying to Mostar with members of his government to take part to an economic conference. On approach by night and limited visibility due to marginal weather conditions, the aircraft struck the slope of a mountain located near Berkovići, about 32 km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire and all nine occupants were killed.
Probable cause:
The accident was the consequence of a controlled flight into terrain after the crew initiated the approach prematurely. The following contributing factors were identified:
- Poor approach and landing preparation and planning,
- The crew ignored ATC information about the current meteorological situation at Mostar Airport,
- The crew misinterpreted the Final Approach Fix (FAF) with the Intermediate Approach Fix (IAF), causing the aircraft to start the descent prematurely,
- The crew disengaged the autopilot system during the approach while descending in complex meteorological conditions,
- Poor crew resources management,
- Lack of crew communication,
- The crew failed to comply with SOP's,
- Failure of the pilot-in-command to maintain flight level when the aircraft reached the MDA and failure of the second pilot to give adequate assistance.
Final Report:

Crash of a Cessna 500 Citation I near Cagliari: 6 killed

Date & Time: Feb 24, 2004 at 0549 LT
Type of aircraft:
Operator:
Registration:
OE-FAN
Flight Type:
Survivors:
No
Site:
Schedule:
Rome – Cagliari
MSN:
500-0289
YOM:
1976
Flight number:
CIT124
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5472
Captain / Total hours on type:
2709.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
1600
Aircraft flight hours:
6471
Aircraft flight cycles:
5618
Circumstances:
The aircraft departed Rome-Ciampino Airport on an ambulance flight to Cagliari, carrying three pilots, three doctors and a cooler containing a heart for a patient. The descent to Cagliari-Elmas Airport was initiated by night under VFR mode. After the crew was cleared to descend to 2,500 feet, ATC reported runway 32 in use and asked the crew to report on short final. About two minutes later, at an altitude of 3,333 feet, the aircraft struck the slope of Mt Su Baccu Malu located 32 km northeast of Cagliari Airport. The aircraft was totally destroyed by impact forces and all six occupants were killed.
Probable cause:
The accident, classified as CFIT, was caused by the conduct of the flight at a height significantly below the Area Minimum Altitude, insufficient to maintain the separation from the ground during a night visual approach in the absence of adequate visual reference.
possible contributory factors that have been identified:
- The aircraft instrumentation did not include a GPWS or TAWS, whose installation is not required by law;
- The erroneous descent by visual flight references, confusing the Elmas runway lights, given that the crew had no special familiarity with the area of Cagliari, the onset of a perspective illusions phenomena, with specific reference to the so-called "black hole approach";
- The misunderstanding by crew members, of the Cagliari Approach controllers instruction to transfer to Elmas TWR ('CIT 124 continue not below 2500 feet, further descent with Elmas TWR 120.6 bye') which may have created the impression, despite the crew had confirmed that they are able to separate themselves from the obstacles that the descent down was free of obstructions;
- Failure to use published procedures and available instruments in a descent to a closer airport and in an unfamiliar area , under conditions of total darkness;
- The anticipation of the deviation from the airway perhaps caused [the crew] to try to speed up the arrival at destination, which determined overflying areas of higher elevation;
- Read errors of the elevations listed in the maps consulted, facilitated by the non representation of the ground color;
- The extended period of wakefulness without adequate rest, which may have contributed to a reduction in the performance of the crew.
Final Report:

Crash of a Learjet 25B in Fort Lauderdale

Date & Time: Feb 20, 2004 at 2157 LT
Type of aircraft:
Operator:
Registration:
N24RZ
Flight Type:
Survivors:
Yes
Schedule:
San Juan – Fort Lauderdale
MSN:
25-159
YOM:
1974
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4500
Aircraft flight hours:
4104
Circumstances:
The captain and first officer were conducting a CFR Part 135 on-demand charter flight, returning two passengers to the accident airplane's base airport. The multi-destination flight originated from the accident airport, about 16 hours before the accident. On the final leg of the flight, the flight encountered stronger than anticipated headwinds, and the first officer voiced his concern several times about the airplane's remaining fuel. As the flight approached the destination airport, the captain became concerned about having to fly an extended downwind leg, and told the ATCT specialist the flight was low on fuel. The ATCT specialist then cleared the accident airplane for a priority landing. According to cockpit voice recorder (CVR) data, while the crew was attempting to lower the airplane's wing flaps in preparation for landing, they discovered that the flaps would not extend beyond 8 degrees. After the landing gear was lowered, the captain told the first officer, in part: "The gear doors are stuck down.... no hydraulics." The captain told the first officer: "Okay, so we're gonna do, this is gonna be a ref and twenty...All right, probably not going to have any brakes..." According to a ATCT specialist in the control tower, the airplane touched down about midway on the 6001-foot long, dry runway. It continued to the end of the runway, entered the overrun area, struck a chain link fence, crossed a road, and struck a building. During a postaccident interview, the captain reported that during the landing roll the first officer was unable to deploy the airplane's emergency drag chute. He said that neither he nor the first officer attempted to activate the nitrogen-charged emergency brake system. The accident airplane was not equipped with thrust reversers. A postaccident examination of the accident airplane's hydraulic pressure relief valve and hydraulic pressure regulator assembly revealed numerous indentations and small gouges on the exterior portions of both components, consistent with being repeatedly struck with a tool. When the hydraulic pressure relief valve was tested and disassembled, it was discovered that the valve piston was stuck open. The emergency drag chute release handle has two safety latches that must be depressed simultaneously before the parachute will activate. An inspection of the emergency drag chute system and release handle disclosed no pre accident mechanical anomalies.
Probable cause:
The pilot in command's misjudged distance/speed while landing, and the flightcrew's failure to follow prescribed emergency procedures, which resulted in a runway overrun and subsequent collision with a building. Factors associated with the accident are the flightcrew's inadequate in-flight planning/decision making, which resulted in a low fuel condition; an open hydraulic relief valve, and inadequate maintenance by company maintenance personnel. Additional factors were an inoperative (normal) brake system, an unactivated emergency drag chute, the flightcrew's failure to engage the emergency brake system, and pressure placed on the flightcrew due to conditions/events.
Final Report:

Crash of a Piper PA-31-325 Navajo C/R in Kahului

Date & Time: Feb 18, 2004 at 1352 LT
Type of aircraft:
Registration:
C-GPTE
Flight Type:
Survivors:
Yes
Schedule:
Honolulu – Oakland – Brooks
MSN:
31-7712059
YOM:
1977
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7923
Circumstances:
The airplane collided with terrain 200 yards short of the runway during an emergency landing following a loss of engine power. The pilot was on an intermediate leg of a ferry trip. Approximately 300 miles from land, the fuel flow and boost pump lights illuminated. Then, the right engine failed. The pilot flew back to the nearest airport; however, approximately 200 yards from the runway, the airplane stalled and the right wing dropped and collided with the ground. The fuel system had been modified a few months prior to the accident to allow for a ferry fuel tank installation. Post accident examination of the airplane could not find a reason for the power loss.
Probable cause:
The pilot's failure to maintain an adequate airspeed while maneuvering for landing on one engine, which resulted in an inadvertent stall. The loss of power in one engine for undetermined reasons was a factor.
Final Report: