Crash of a Learjet 25B in Del Rio: 1 killed

Date & Time: Sep 19, 2003 at 1710 LT
Type of aircraft:
Operator:
Registration:
N666TW
Flight Type:
Survivors:
Yes
Schedule:
El Paso – Del Rio
MSN:
25-116
YOM:
1973
Flight number:
AJI892
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
4689
Captain / Total hours on type:
1348.00
Copilot / Total flying hours:
2783
Copilot / Total hours on type:
263
Aircraft flight hours:
15363
Circumstances:
The cargo flight was cleared for a visual approach to the 5,000-foot long, by 150-foot wide asphalt runway. Based on estimated landing weight of the aircraft, the Vref was estimated at 116 KIAS. Air traffic Control (ATC) radar data revealed that the flight maintained a ground speed above 190 knots on final approach, to include the touchdown zone for runway 13. The first evidence of braking was noted at a point 1,247 feet from the departure end of the runway. Braking signatures on the asphalt as well as off the pavement were consistent with an operational anti-skid system. Witnesses at the airport also observed the airplane flying very fast and touching down long. Both crewmembers, the 4,689-hour captain and the 2,873-hour first officer, were familiar with the airport, and the flight was 20 minutes ahead of its scheduled arrival time. The airplane overran the departure end of runway 13, impacted the airport perimeter fence, proceeded across a roadway, took out another fence, and collided with two trees in a cemetery. The airplane was found to be within weight and balance limits for all phases of the flight. The installed cockpit voice recorder (CVR) was found not to be functional.
Probable cause:
The pilot's misjudged distance and speed during the approach to landing, and his failure to obtain the proper touchdown point resulting in an overrun. A contributing factor was the pilot's failure to abort the landing.
Final Report:

Crash of a BAe 3201 Jetstream 32EP in Luleå

Date & Time: Sep 17, 2003 at 1828 LT
Type of aircraft:
Operator:
Registration:
SE-LNT
Flight Type:
Survivors:
Yes
Schedule:
Pajala – Luleå
MSN:
948
YOM:
1991
Flight number:
EXC403
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
31000
Captain / Total hours on type:
2000.00
Copilot / Total flying hours:
660
Copilot / Total hours on type:
237
Aircraft flight hours:
13494
Circumstances:
The pilots were scheduled to fly the aircraft, a BAe Jetstream 32, on scheduled flight EXC403 from Pajala Airport to Luleå/Kallax Airport. This was the third flight together for the day. Before takeoff they noted that the flight was planned without passengers. Since the co-pilot was shortly to undergo an Operator’s Proficiency Check and the commander had long flying experience, including as an instructor, the commander decided to take the opportunity to have the co-pilot train flying with simulated engine failure. The takeoff from Pajala was at 17.57 hrs with the co-pilot as Pilot Flying. During the climb the commander reduced thrust on the right engine to simulate engine failure. This was done by moving the engine control lever to its rear stop. The commander understood this to represent what is termed ”simulated feather” in which an engine generates no drag and causes the least possible resistance. The exercise passed off without problem and the co-pilot had no difficulties in handling the aircraft. It was decided to practise flying with simulated engine failure during the landing as well. During the approach to Luleå/Kallax Airport when the aircraft was at an altitude of about 3500 feet the commander accordingly reduced thrust on the right engine once again. The co-pilot understood that the whole landing, including touchdown, would be with one engine on reduced thrust. However, the commander’s intention was to restore normal thrust on the right engine before touchdown. Prior to landing the reference speed (Vref1) had been calculated at 107 knots IAS2 and the flaps lowered 20°, based on the calculated landing mass of 5 640 kg. During the approach when the aircraft was at about 3500 feet, the commander reduced right engine thrust. According to the FDR recording thrust was reduced initially to just over 19 % and subsequently, for six minutes, further to just under 11% at the same time as altitude decreased to 900 feet. The co-pilot flew the aircraft in a right turn to runway 32 and started his final 2 nautical miles from the runway threshold at a height of 900 feet. The final was entered with a somewhat higher glide angle than normal. As the aircraft approached the runway threshold the thrust on the right engine had decreased to approximately 7%. The approach took place with applied rudder and opposite banking to counteract the lateral forces generated by the asymmetrical thrust. During the approach the co-pilot experienced an inertia in the ailerons that he had never experienced previously. Shortly after the aircraft had crossed the runway threshold and was about 5 metres above the runway, both the co-pilot and the commander felt how the aircraft suddenly yawed and rolled to the right. Neither pilot remembers hearing the stall warning sounding. Despite application of full aileron and rudder the pilots were unable to stop the aircraft’s uncontrolled motion. This continued until the right wing tip hit the ground. The fuselage then struck the ground. The aircraft slid on its belly about 50 metres alongside the runway before stopping. The pilots hastily evacuated the aircraft. The accident was observed by the air traffic controller who immediately alarmed the airport rescue service, which arrived at the accident scene within a minute or so. After its arrival the commander boarded the aircraft and turned off the fuel supply and the main electricity, whereafter the rescue service covered the aircraft with foam. The accident occurred on 17 September 2003 at 18.28 hrs in position 6532N 02207E; 20 m above sea level in daylight.
Probable cause:
The accident was caused by shortcomings in the company’s quality assurance system, operational routines and regulations. These contributed to the facts that:
- the commander considered he was able to serve as a flying instructor on an aircraft type and in a flight situation for which he was neither qualified nor authorised,
- the pilot's lacked necessary familiarity with the aircraft type’s special flight characteristics during asymmetrical thrust, and
- the pilot's lacked familiarity with the regulations in force for flying training.
Final Report:

Crash of a BAe 3102 Jetstream 31 in Wick

Date & Time: Sep 17, 2003 at 1447 LT
Type of aircraft:
Operator:
Registration:
G-EEST
Survivors:
Yes
Schedule:
Aberdeen – Wick
MSN:
781
YOM:
1987
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7885
Captain / Total hours on type:
1195.00
Copilot / Total flying hours:
6800
Copilot / Total hours on type:
1000
Aircraft flight hours:
17845
Aircraft flight cycles:
20730
Circumstances:
The aircraft was landing on Runway 31 at Wick Airport. It crossed the threshold at 130 kt which was 21 kt faster than the correct threshold speed. After the co-pilot closed the power levers the aircraft floated about six feet above the runway surface. The aircraft touched down and bounced before touching down a second time more heavily, cracking a wing spar and flexing the aircraft structure sufficient to allow the right propeller to contact the runway. The aircraft bounced again before touching down for the third and final time. The investigation determined that just before the first touchdown, one or both power levers were moved aft of the flight idle position. It was concluded that both the commander and co-pilot were making inputs on the flying controls from that moment onwards until after the second, heavy touchdown. There was no evidence of any technical fault on the aircraft and the weather conditions were well within the limitations set for the aircraft. No safety recommendations were made.
Probable cause:
It is reasonable to conclude that the manoeuvres conducted by G-EEST during the landing were the result of combined control inputs made by the commander and co-pilot. The evidence indicates that this period of combined control started at least 0.28 seconds before the first touchdown and finished at some stage after the second and damaging touchdown. After the first touchdown the aircraft became airborne in a high-drag, low-lift configuration which was intended for ground operation only and a 5.6g impact ensued on the second touchdown. There was no evidence of any technical fault on the aircraft that could have been a factor and the meteorological conditions were within the limitations set for the aircraft. A more complete understanding of the accident might have been possible with additional flight data parameters such as engine performance, aircraft pitch, and power lever position.
Final Report:

Crash of a Cessna 208B Grand Caravan near Summer Beaver: 8 killed

Date & Time: Sep 11, 2003 at 2130 LT
Type of aircraft:
Operator:
Registration:
C-FKAB
Survivors:
No
Schedule:
Pickle Lake - Summer Beaver
MSN:
208B-0305
YOM:
1992
Flight number:
WSG125
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
2351
Captain / Total hours on type:
946.00
Aircraft flight hours:
16770
Circumstances:
The aircraft departed Pickle Lake to Summer Beaver, Ontario, on a charter flight with seven passengers and one crew member. The flight proceeded on a direct routing to destination at 3500 feet above sea level under night visual flight conditions. On approaching Summer Beaver, the aircraft joined the circuit on a downwind leg for a landing on Runway 17. When the aircraft did not land, personnel at Summer Beaver contacted the Pickle Lake flight dispatch to inquire about the flight. The aircraft was declared missing following an unsuccessful radio search by the Pickle Lake flight dispatch staff. Search and rescue personnel found the wreckage in a wooded area three nautical miles northwest of Summer Beaver. The aircraft had been nearly consumed by a post-crash fire. All eight people on board had been fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
The aircraft departed controlled flight and struck terrain for undetermined reasons.
Findings as to Risk:
The company's flight-following procedures for flights operating in remote areas were impractical and were not consistently applied; this could compromise timely search and rescue operations following an accident.
Other Findings:
The aircraft did not carry flight recorders. Lack of information about the cause of this accident affects TSB's ability to identify related safety deficiencies and to issue safety communications intended to prevent accidents that could occur under similar circumstances.
Final Report:

Crash of a PZL-Mielec AN-2R in Trollhättan

Date & Time: Aug 26, 2003 at 1730 LT
Type of aircraft:
Registration:
LY-KAE
Flight Type:
Survivors:
Yes
Schedule:
Trollhättan - Trollhättan
MSN:
1G196-54
YOM:
1982
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Upon landing at Trollhättan-Målöga Airport, the aircraft nosed over and came to rest upside down. Both occupants escaped uninjured while the aircraft was damaged. It was apparently repaired.
Probable cause:
The pilot used excessive brakes after touchdown, causing the brakes to block. The landing maneuver was completed with a tailwind component.

Crash of a Piper PA-31-310 Navajo in Clearwater: 2 killed

Date & Time: Aug 21, 2003 at 1648 LT
Type of aircraft:
Registration:
N93DC
Flight Type:
Survivors:
Yes
Site:
Schedule:
Saint Augustine - Clearwater
MSN:
31-7712017
YOM:
1977
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
760
Copilot / Total flying hours:
600
Aircraft flight hours:
6019
Circumstances:
The airplane experienced an in-flight loss of control and crashed into a residential area. The flight departed VFR and when near the destination airport flew between areas with VIP Level 5 reflectivity. There was no record of a preflight weather briefing. The flight continued towards the destination airport and encountered lesser intensity reflectivity. An individual at the destination airport reported hearing an occupant of the airplane ask, "...for an advisory for the field", and "...what the weather was like." The individual at the airport advised that the winds appeared to be in favor for runway 16, which was left hand traffic, the runway was wet, and the rain seemed to be letting up. There were no further communications from the accident aircraft. A pilot-rated witness located north of the destination airport, and nearly due west of the accident site reported seeing the airplane on what he thought was final approach to runway 16, but the airplane was "very low." The witness reported the airplane made a, "sudden, sharp turn to the left [flying eastbound]." He then lost sight of the airplane and proceeded to the accident site. Another pilot-rated witness who was located in a vehicle approximately 1/4 mile west-northwest of the accident site reported observing an airplane flying from the northwest. The airplane banked to the left flying eastbound at a, "...very slow airspeed and banking and yawing left and right." While flying eastbound it appeared to him that whomever was flying the airplane was executing a go-around as evidenced by the landing gear retracting, followed by the flaps. The airplane then appeared to climb which appeared very unstable, again yawing left and right. The airplane then banked to the right, stalled, and entered a spin impacting the ground. Still another witness who was located approximately 1/10th of a nautical mile east-southeast from the accident site reported he came out of his house after the rain ended and was facing west. He saw the accident airplane from the northwest and thought it had descended lower than normal. The airplane was flying above the tops of nearby trees and while flying in a southeasterly direction, pitched up, "darn near got 90 degrees", rolled to the left, and descended straight down. He reported that he did not hear the engines, and thought he should have been able to hear them if the pilot had "revved them up." He estimated his view of the flight lasted approximately 10-15 seconds, and couldn't tell if the landing gear was extended. He did not see any smoke trailing the airplane, and after the impact he ran into his house, called 911, got into his car, and drove to the scene. He heard an explosion, and saw flames. He got to the airplane and helped rescue a passenger who was beating on the aircraft's door. The airplane descended nearly vertical in a residential area and damaged trees approximately 30 feet above ground level. A post crash fire consumed the cockpit, cabin, portions of both wings, and portions of both engines. Examination of the flight controls, both engines, propellers, and propeller governors revealed no evidence of preimpact mechanical failure or malfunction. Accessories of both engines including the magnetos were destroyed by the post crash fire. Additionally, both servo fuel injectors were heat damaged which precluded bench testing. During disassembly of the right servo fuel injector, the hub stud was found separated from the hub at the fuel diaphragm. No determination was made whether this occurred during disassembly or occurred preimpact. No determination could be made as to who was operating the controls at the time of the accident.
Probable cause:
The failure of the flightcrew to maintain airspeed (Vs) resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with the ground.
Final Report:

Crash of a Beechcraft T-1A Jayhawk in Biloxi

Date & Time: Aug 16, 2003 at 2221 LT
Type of aircraft:
Operator:
Registration:
91-0093
Flight Type:
Survivors:
Yes
Schedule:
Del Rio - Biloxi
MSN:
TT-34
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Mishap Student pilot (MSP) was flying an Instrument Landing System (ILS) approach to runway 21 at Keesler AFB. They were in Visual Meteorological Conditions (VMC) at night and the runway was wet. After some deviations on the approach, they arrived over the threshold on a normal glide slope and faster (about 114 kts) than the computed approach speed of 108 kts. The aircraft touched down approximately 1500 feet down the runway. The Mishap Instructor Pilot (MIP) actuated the speed brakes/spoilers switch and the student began to immediately apply brake pressure. After 4-5 seconds, the instructor recognized that the aircraft was not decelerating and declared that she was taking control of the aircraft. The instructor immediately applied maximum braking with no perceived deceleration. She then grabbed the glare shield in an attempt to gain additional leverage on the brakes and again felt no perceived deceleration. At this point, the aircraft was rapidly running out of available runway. The instructor selected the emergency brakes just prior to arriving at the departure end threshold and the brakes locked resulting in a hydroplane skid. The aircraft departed the prepared surface and came to a halt 190 feet later. As a result of the runway departure, the right main and nose gear collapsed, and the forward fuselage and both wings were heavily damaged.
Probable cause:
Based on clear and convincing evidence, the Board President determined that this mishap was caused by a combination of several factors during the landing sequence. First, the Mishap Student Pilot (MSP) flew faster than the computed approach and landing speeds. Additionally she maintained higher than idle thrust for the first few seconds after touchdown. Because of these factors, the aircraft did not settle completely on the runway after touchdown-as the struts were not completely compressed. This put the aircraft systems in the "AIR" mode meaning that the speed brakes/spoilers could not deploy. Finally, the runway was wet; and the crew was inexperienced and thus did not recognize the anti-skid cycling at high speeds on the wet runway.

Crash of a Learjet 35A in Cancún

Date & Time: Aug 14, 2003 at 2222 LT
Type of aircraft:
Registration:
N403FW
Flight Type:
Survivors:
Yes
Schedule:
Fort Lauderdale - Cancún
MSN:
35-403
YOM:
1981
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
7950
Circumstances:
On August 14, 2003, about 2222 central daylight time, a Gates LearJet Corporation 35A, N403FW, registered to Aircraft Holdings LLC, operated by Air America Flight Services, Inc., was landed with the landing gear retracted at the Cancun International Airport, Cancun, Mexico. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed for the 14 CFR Part 91 positioning flight. The airplane was substantially damaged and there were no injuries to the airline transport rated pilot and copilot, nor to the three medical personnel on board the airplane. The flight originated about 2145 eastern daylight time from the Fort Lauderdale Executive Airport, Fort Lauderdale, Florida. According to the director of operations for the operator, the airplane was cleared for a visual approach to runway 12, and the flightcrew advised him they did read the landing checklist. The landing gear was down and locked as indicated by the three green lights; though they didn't recall if the landing gear was extended as evidenced by the landing lights. They also advised him of feeling fuselage to runway surface contact; the airplane slid approximately 4,000 feet before coming to rest upright. Following the occurrence, the nose of the airplane was raised and the nose landing gear was observed to be inside the wheel well. Emergency extension of the landing gear was initiated and the nose landing gear extended and locked; the main landing gear did not extend as fuselage to runway contact prevented extension of the main landing gears. The airplane was dragged from the runway where approximately 2 days later, a crane raised the airplane. At that time, the main landing gears which were in the wheel wells, extended and locked into position.

Crash of a Let L-410UVP in Rumbek

Date & Time: Aug 13, 2003
Type of aircraft:
Operator:
Registration:
9XR-JT
Survivors:
Yes
Schedule:
Lokichogio - Rumbek
MSN:
81 07 07
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Lokichogio on a charter flight to Rumbek on behalf of a humanitarian agency. On final approach, the captain saw an animal crossing the runway and decided to delay the landing. The aircraft landed too far down the runway and was unable to stop within the remaining distance. It overran and came to rest few dozen meters further. All five occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Cessna 208B Grand Caravan in Tocomita: 1 killed

Date & Time: Aug 8, 2003 at 0932 LT
Type of aircraft:
Operator:
Registration:
YV-1069C
Survivors:
Yes
Schedule:
Porlamar - Canaima
MSN:
208B-0713
YOM:
1998
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
En route from Porlamar to Canaima, the crew informed ATC about engine problems and was cleared to divert to Tocomita for an emergency landing. On final approach, the aircraft stalled and crashed into trees 100 meters short of runway. A passenger was killed while 15 other occupants were injured. The aircraft was destroyed.