Crash of a Cessna 441 Conquest in Greenacres City: 1 killed

Date & Time: Dec 30, 2003 at 1115 LT
Type of aircraft:
Operator:
Registration:
N111RC
Flight Type:
Survivors:
No
Schedule:
Boca Raton – West Palm Beach
MSN:
441-0188
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
5832
Aircraft flight hours:
4036
Circumstances:
The airplane, flown by an airline transport pilot, departed in day visual meteorological conditions for an 18-nautical mile flight from the home base airport to another airport where the pilot planned to conduct a practice instrument approach. The pilot contacted approach control and requested a practice ILS approach. The controller instructed the pilot to proceed northwest bound and maintain 2,500 feet msl. Radar indicated the airplane tracked a northerly heading instead of a northwesterly heading as instructed. The airplane continued on a northerly heading until 1113:48 when it was about 5 miles southwest of the destination airport at 1,900 feet msl with a ground speed of 172 knots. At this point, the controller instructed the pilot to turn southbound and remain clear of Class C airspace. Radar coverage for the next 50 seconds was intermittent. At 1114:29, radar picked up the airplane about 4 miles southwest of the destination airport at 1,800 feet msl, a ground speed of 106 knots, and a heading of 101 degrees. The airplane continued heading east-southeast for about 30 seconds and its ground speed continued to decay. At 1114:58, it entered an abrupt descent, going from 1700 feet to 200 feet in 15 seconds. The last radar return was recorded at 1115:13 and showed the airplane at 200 feet msl, a ground speed of 64 knots, and a heading of 093 degrees. Several witnesses observed the airplane descend in a "flat spin" and impact a shallow canal in a residential area. Examination of the accident site revealed that the airplane impacted the canal in a nearly flat and level attitude. No evidence of any pre-impact mechanical discrepancies with the airframe or engines was found that would have prevented normal operation. Testing of the electronic engine controls revealed that both units were functional, but under some conditions would trip to manual mode. Further investigation determined that the units tripping to manual mode was due to an electrical overstress that failed the same thermistor within each unit. The reason for the electrical overstress or when it occurred could not be determined; however, it is probable it occurred at impact when the units were submerged in water. Even if the units tripped to manual mode in flight, this would only result in the loss of the torque and temperature limiting and propeller synchrophaser systems, meaning the pilot would have to manually adjust the power levers as required to maintain the proper torque and exhaust gas temperature. Post accident toxicology testing of the pilot's blood revealed chlorpheniramine, an over-the-counter sedating antihistamine, at more than ten times higher than the level expected with a typical maximum over-the-counter dose. It is probable that the pilot's performance and judgment were substantially impaired by his very high blood level of chlorpheniramine.
Probable cause:
The pilot's failure to maintain aircraft control, which resulted in an inadvertent stall/spin and subsequent uncontrolled descent into a canal. A factor was the pilot's impairment by the drug
chlorpheniramine.
Final Report:

Crash of a Boeing 737-3Y0 in Libreville

Date & Time: Dec 19, 2003 at 1844 LT
Type of aircraft:
Operator:
Registration:
TR-LFZ
Survivors:
Yes
Schedule:
Franceville – Libreville
MSN:
23750
YOM:
1987
Flight number:
GN471
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
125
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Libreville-Léon Mba Airport, the crew encountered poor weather conditions. Due to low visibility caused by heavy rain falls, a landing was not possible and the crew followed a holding pattern of about 30 minutes for weather improvement. After landing on runway 16 (3,000 metres long), the aircraft was unable to stop within the remaining distance. It overran at a speed of 100 knots, collided with a fence and came to rest 100 metres further. All 131 occupants evacuated safely while the aircraft was damaged beyond repair. It was reported that the left engine throttle lever was in a full forward position after touchdown while the right engine throttle lever was in the reverse position. The braking action was poor because the runway surface was poor and the crew did not initiate a go-around procedure.

Crash of a Douglas DC-10-10 in Memphis

Date & Time: Dec 18, 2003 at 1226 LT
Type of aircraft:
Operator:
Registration:
N364FE
Flight Type:
Survivors:
Yes
Schedule:
Oakland – Memphis
MSN:
46600
YOM:
1971
Flight number:
FDX647
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
21000
Captain / Total hours on type:
2602.00
Copilot / Total flying hours:
15000
Copilot / Total hours on type:
1918
Aircraft flight hours:
65375
Aircraft flight cycles:
26163
Circumstances:
On December 18, 2003, about 1226 central standard time, Federal Express Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10), N364FE, crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main landing gear collapsed after touchdown on runway 36R, and the airplane veered off the right side of the runway. After the gear collapsed, a fire developed on the right side of the airplane. Of the two flight crewmembers and five non revenue FedEx pilots on board the airplane, the first officer and one non revenue pilot received minor injuries during the evacuation. The post crash fire destroyed the airplaneís right wing and portions of the right side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport (OAK), Oakland, California, about 0832 (0632 Pacific standard time) and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan.
Probable cause:
The National Transportation Safety Board determines that the probable causes of the accident were:
1) the first officerís failure to properly apply crosswind landing techniques to align the airplane with the runway centerline and to properly arrest the airplaneís descent rate (flare) before the airplane touched down; and
2) the captain's failure to adequately monitor the first officerís performance and command or initiate corrective action during the final approach and landing.
Final Report:

Crash of a Beechcraft 99 Airliner in Wausau

Date & Time: Dec 16, 2003 at 0730 LT
Type of aircraft:
Operator:
Registration:
N399CZ
Flight Type:
Survivors:
Yes
Schedule:
Milwaukee – Wausau
MSN:
U-52
YOM:
1969
Flight number:
FRG1544
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9000
Captain / Total hours on type:
55.00
Aircraft flight hours:
35914
Circumstances:
The airplane sustained substantial damage during a hard landing. The pilot stated, "On approach to rwy 8 at [Central Wisconsin Airport] I got high [and] right of course. When I broke out of clouds around 1000 [feet above ground level] I saw the runway, realizing I was high I pulled the power back [and] increased my rate of descent. I started to arrest my rate of descent [and] add power to keep my speed up. The engines didn't spool up in time resulting in a hard [landing]. I noticed the right wing was a little low taxing in so I thought maybe I blew a tire on landing. Not until I shut down [and] got out did I realize I hit the prop about an inch back [and] the engine nacelle dropped down several inches in front." The weather was: Wind 330 degrees at 8 knots; visibility 4 statute miles; present weather light snow; sky condition overcast 300 feet; temperature 1 degree C; dew point -1 degree C; altimeter 29.41 inches of mercury. The pilot reported that the flight did not have any mechanical malfunctions.
Probable cause:
The pilot's failure to maintain the proper descent rate and his inadequate flare.
Final Report:

Crash of a Cessna 421C Golden Eagle III in Upland: 1 killed

Date & Time: Dec 15, 2003 at 1723 LT
Registration:
N6887L
Flight Type:
Survivors:
No
Schedule:
Camarillo – Upland
MSN:
421C-1113
YOM:
1981
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
600
Captain / Total hours on type:
175.00
Aircraft flight hours:
3257
Circumstances:
The airplane impacted a residence during a missed approach. After completing the en route portion of the instrument flight, a controller cleared the pilot to proceed direct to the initial approach fix for the global positioning satellite (GPS) approach to the airport. After being cleared for the approach, the airplane continued on a course to the east and at altitudes consistent with flying the GPS published approach procedure. Radar data indicated that at the missed approach point at the minimum descent altitude of 2,000 feet msl, the airplane made a turn to the left, changing course in a northerly direction toward rapidly rising mountainous terrain. The published missed approach specified a climbing right turn to 4,000 feet, and noted that circling north of the airport was not allowed. Remaining in a slight left turn, the airplane climbed to 3,300 feet msl over the duration of 1 minute 9 seconds. The controller advised the pilot that he was flying off course toward mountainous terrain and instructed him to make an immediate left turn heading in a southbound direction. The airplane descended to 3,200 feet msl and made a left turn in a southerly direction. The airplane continued to descend to 2,100 feet msl and the pilot read back the instructions that the controller gave him. The airplane then climbed to 3,300 feet, with an indicated ground speed of 35 knots, and began a sharp left turn. It then descended to impact with a house. At no time during the approach did the pilot indicate that he was experiencing difficulty navigating or request assistance. An examination of the airplane revealed no evidence a mechanical malfunction or failures prior to impact; however, both the cockpit and instrument panel sustained severe thermal damage, precluding any detailed examinations.
Probable cause:
The pilot became lost/disoriented during the approach, failed to maintain course alignment with the missed approach procedure, and subsequently lost control of the airplane.
Final Report:

Crash of a Boeing 737-200 in Lima

Date & Time: Dec 13, 2003 at 2248 LT
Type of aircraft:
Operator:
Registration:
OB-1544-P
Survivors:
Yes
Schedule:
Caracas - Lima
MSN:
20956
YOM:
1974
Flight number:
ACQ341
Country:
Crew on board:
6
Crew fatalities:
Pax on board:
94
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
25502
Copilot / Total flying hours:
2229
Aircraft flight hours:
62716
Aircraft flight cycles:
62162
Circumstances:
Following an uneventful flight from Caracas, the crew started the approach to Lima-Callao-Jorge Chávez Airport when the crew noted an asymmetric warning with the flaps. The crew decided to continue the approach but failed to lower the undercarriage. The aircraft belly landed at a speed of 190 knots and slid on runway 15 for 2,347 metres before coming to rest. All 100 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Failure of the crew to verify and check the Non Normal Checklist of the Quick Reference Handbook (QRH) due to technical problems at the time of approach and landing, causing the omission of the extension of the gear and subsequent contact of the aircraft with the runway with landing gear retracted. The following findings were identified:
- During the approach, an indication of flap asymmetry presented.
- Due to the tightness of the itinerary programmed by the company, the total flight hours and the flight's working day were within the limits of the maximum allowed by the RAP, which could have influenced (due to fatigue) the poor performance by the crew.
- The lack of recording of some parameters of the flight recorders (FDR and CVR) prevented the resolution of some important and useful details for the investigation.
- The flap asymmetry indication, due to an indication fault in the Flap Position Indicator caused by high electrical resistance originating from the winding inside the synchro transmitter of the right side Flap Position Transmitter.
- The omission of the use in the approach phase of the procedures described in the QRH for this type of abnormal situations.
- The lack of decision to carry out a Go Around, taking into account that the period of time to carry out the QRH procedures for this abnormal situation was not going to be enough.
- Overconfidence (complacency) during the approach phase under abnormal conditions (indication of flap asymmetry).
- Lack of Crew Resource Management during the approach and landing phases, especially under abnormal conditions.
- Lack of leadership during the abnormal situation presented.
- Lack of communication with the Control Tower about the abnormal conditions in which the approach and landing were to be carried out.
- Itinerary very adjusted to the limits of flight hours and working hours, established by the RAP.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Guaymas: 2 killed

Date & Time: Dec 13, 2003 at 1540 LT
Registration:
N9223X
Flight Type:
Survivors:
No
Schedule:
Tucson – Guaymas
MSN:
46-22142
YOM:
1993
Location:
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On December 13, 2003, at approximately 1540 central standard time, a Piper PA-46 single-engine airplane, N9223X, was destroyed upon impact with a building about one mile short of the landing threshold for runway 02 at Guaymas State of Sonora, In the Republic of Mexico. The private pilot and his passenger were fatally injured. Visual meteorogical conditions prevailed for the personal cross country trip that originated in Tuscon, Arizona, at 1340, with Guaymas as his final destination.

Crash of a Britten-Norman BN-2A-21 Islander in Tuguegarao: 3 killed

Date & Time: Dec 12, 2003 at 1500 LT
Type of aircraft:
Operator:
Registration:
RP-C868
Flight Type:
Survivors:
No
Schedule:
Maconacon – Tuguegarao
MSN:
725
YOM:
1974
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
On approach to Tuguegarao Airport, the twin engine aircraft entered clouds and the crew lost visual contact with the runway. The aircraft struck a hill top and crashed in a wooded area located 3 km short of runway. All three occupants were killed.

Crash of a Cessna 414 Chancellor in Greeneville: 4 killed

Date & Time: Dec 11, 2003 at 1047 LT
Type of aircraft:
Operator:
Registration:
N1592T
Survivors:
Yes
Schedule:
Columbus – Greeneville
MSN:
414-0372
YOM:
1972
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
4845
Captain / Total hours on type:
160.00
Aircraft flight hours:
4989
Circumstances:
The pilot was on a circling approach for landing in instrument icing conditions. The landing gear were extended and the flaps were lowered to 15°. The alternate air induction system was not activated. The surviving passenger stated when the airplane came out of the clouds and the airplane started to buffet and shake. The pilot was heard to state on the UNICOM frequency by the fixed base operator and a lineman, "Emergency engine ice." The airplane was observed to make a 60-degree angle of bank and collided with trees and terrain. The Pilot's Operating Handbook states the airplane will stall at 129 miles per hour with the landing gear and flaps down at 15-degrees. The maximum landing weight for the Cessna 414 is 6,430 pounds. The total aircraft weight at the crash site was 6,568.52 pounds. Witnesses who knew the pilot stated the pilot had flown one other known flight in icing conditions before the accident flight.
Probable cause:
The pilot's failure to maintain airspeed while maneuvering in icing conditions on a circling approach for landing resulting in an inadvertent stall and collision with trees and terrain. A factor in the accident was a partial loss of engine power due to the pilot's failure to activate the alternate induction air system, and exceeding the maximum landing weight of the airplane.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in Lokichoggio

Date & Time: Dec 7, 2003 at 1337 LT
Type of aircraft:
Operator:
Registration:
5Y-NNN
Survivors:
Yes
Schedule:
Nairobi – Lokichogio
MSN:
11231
YOM:
1986
Flight number:
HSA812
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
23
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Lokichogio Airport, the crew started the braking procedure when the tyre n°1 on the nose gear burst. Unable to stop within the remaining distance, the airplane overran, collided with a fence and came to rest in a ditch with its nose gear torn off. All 27 occupants evacuated safely while the aircraft was damaged beyond repair.