Crash of a Learjet 35A in Groton: 2 killed

Date & Time: Aug 4, 2003 at 0639 LT
Type of aircraft:
Registration:
N135PT
Flight Type:
Survivors:
No
Schedule:
Farmingdale - Groton
MSN:
35-509
YOM:
1983
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4300
Copilot / Total flying hours:
9000
Aircraft flight hours:
9287
Circumstances:
About 5 miles west of the airport, the flightcrew advised the approach controller that they had visual contact with the airport, canceled their IFR clearance, and proceeded under visual flight rules. A witness heard the airplane approach from the east, and observed the airplane at a height consistent with the approach minimums for the VOR approach. The airplane continued over the runway, and entered a "tight" downwind. The witness lost visual contact with the airplane due to it "skimming" into or behind clouds. The airplane reappeared from the clouds at an altitude of about 200 feet above the ground on a base leg. As it overshot the extended centerline for the runway, the bank angle increased to about 90-degrees. The airplane then descended out of view. The witness described the weather to the north and northeast of the airport, as poor visibility with "scuddy" clouds. According to CVR and FDR data, about 1.5 miles from the runway with the first officer at the controls, and south of the extended runway centerline, the airplane turned left, and then back toward the right. During that portion of the flight, the first officer stated, "what happens if we break out, pray tell." The captain replied, "uh, I don't see it on the left side it's gonna be a problem." When the airplane was about 1/8- mile south of the runway threshold, the first officer relinquished the controls to the captain. The captain then made an approximate 60-degree heading change to the right back toward the runway. The airplane crossed over the runway at an altitude of 200 feet, and began a left turn towards the center of the airport. During the turn, the first officer set the flaps to 20 degrees. The airplane reentered a left downwind, about 1,100 feet south of the runway, at an altitude of 400 feet. As the airplane turned onto the base leg, the captain called for "flaps twenty," and the first officer replied, "flaps twenty coming in." The CVR recorded the sound of a click, followed by the sound of a trim-in-motion clicker. The trim-in-motion audio clicker system would not sound if the flaps were positioned beyond 3 degrees. About 31 seconds later, the CVR recorded a sound similar to a stick pusher stall warning tone. The airplane impacted a rooftop of a residential home about 1/4-mile northeast of the approach end of the runway, struck trees, a second residential home, a second line of trees, a third residential home, and came to rest in a river. Examination of the wreckage revealed the captain's airspeed indicator reference bug was set to 144 knots, and the first officer's was set to 124 knots. The flap selector switch was observed in the "UP" position. A review of the Airplane Flight Manual revealed the stall speeds for flap positions of 0 and 8 degrees, and a bank angle of 60 degrees, were 164 and 148 knots respectfully. There were no charts available to calculate stall speeds for level coordinated turns in excess of 60 degrees. The flightcrew was trained to apply procedures set forth by the airplane's Technical Manual, which stated, "…The PF (Pilot Flying) will call for flap and gear extension and retraction. The PNF (Pilot not flying) will normally actuate the landing gear. The PNF will respond by checking appropriate airspeed, repeating the flap or gear setting called for, and placing the lever in the requested position... The PNF should always verify that the requested setting is reasonable and appropriate for the phase of flighty and speed/weight combination."
Probable cause:
The first officer's inadvertent retraction of the flaps during the low altitude maneuvering, which resulted in the inadvertent stall and subsequent in-flight collision with a residential home. Factors in the accident were the captain's decision to perform a low altitude maneuver using excessive bank angle, the flight crews inadequate coordination, and low clouds surrounding the airport.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Sully Lake: 1 killed

Date & Time: Aug 2, 2003 at 1700 LT
Type of aircraft:
Registration:
C-GUXW
Flight Type:
Survivors:
Yes
Schedule:
Pelican Narrows - Sully Lake
MSN:
611
YOM:
1954
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The single engine aircraft departed Pelican Narrows with two passengers and one pilot on board. While approaching Sully Lake, the engine lost power. The aircraft lost height and crashed in Sully Lake. Both passengers exited the cabin and were seriously injured while the pilot was killed. They spent a night on the shore and were rescued and evacuated to hospital a day later.
Probable cause:
A cracked cylinder resulted in a loss of engine power and the pilot attempted a force landing on a small lake. The altitude at which the event began may have given the pilot very little time to successfully complete a forced landing.

Crash of a Douglas C-54G-10-DO Skymaster in Ulu

Date & Time: Aug 2, 2003 at 0800 LT
Type of aircraft:
Operator:
Registration:
C-GBSK
Flight Type:
Survivors:
Yes
MSN:
36049
YOM:
1945
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft was completing a cargo flight to Ulu, carrying four crew members and a load consisting of 45 oil drums. On final approach, the crew realized his speed was too high so he reduced engine power and selected full flaps. The aircraft lost height so power was added. But the aircraft continued to descent and struck the ground short of runway threshold. Upon impact, the undercarriage were torn off. The aircraft slid on its belly, lost its both wings and came to rest few hundred feet further. All four crew members escaped with minor injuries and the aircraft was damaged beyond repair.

Crash of a Piper PA-31-350 Navajo Chieftain in Corozal

Date & Time: Jul 31, 2003
Operator:
Registration:
ARC-511
Flight Type:
Survivors:
Yes
MSN:
31-7405151
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while on approach to Corozal-Las Brujas Airport. All three occupants were injured and the aircraft was destroyed.

Crash of a Cessna 551 Citation II/SP in Sorocaba: 1 killed

Date & Time: Jul 23, 2003 at 0840 LT
Type of aircraft:
Operator:
Registration:
PT-LME
Flight Type:
Survivors:
Yes
Schedule:
Lins - Sorocaba
MSN:
551-0023
YOM:
1980
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
3920
Captain / Total hours on type:
1300.00
Copilot / Total flying hours:
1000
Copilot / Total hours on type:
90
Aircraft flight hours:
8761
Circumstances:
The aircraft departed Lins Airport on a ferry flight to Sorocaba with two pilots on one passenger (the owner) on board. The aircraft was transferred to Sorocaba Airport for maintenance purposes. While descending, the crew was informed that runway 36 was in use and that three small aircraft were completing local training in the circuit. In good weather conditions, the captain decided to complete a straight-in approach to runway 18. After touchdown, the aircraft was unable to stop within the remaining distance. It overran, crossed a road and came to rest into a ravine. The passenger escaped uninjured, the copilot was seriously injured and the captain was killed. The aircraft was destroyed.
Probable cause:
Wrong approach configuration on part of the crew who completed an unstabilized approach and landed too far down the runway (about a half way down) at an excessive speed. In such conditions, the aircraft could not be stopped within the remaining distance. The following contributing factors were identified:
- The crew did not make any approach briefing,
- The crew failed to follow the approach checklist,
- The aircraft had deficiencies in maintenance, particularly with regard to the brakes systems,
- The techlogs were out of date,
- Maintenance was periodic but insufficient,
- Although the runway 36 was in use, the captain preferred to land on runway 18,
- The aircraft was unstable on short final and landed too far down the runway, reducing the landing distance available,
- The aircraft' speed upon landing was excessive, preventing the reverse thrust systems to be activated,
- The captain took over control and activated the reverse thrust system on the right engine only,
- Poor crew coordination,
- The crew was operating in a conflict environment after touchdown,
- Poor judgment of the situation,
- Poor flight planning,
- Lack of crew discipline.
Final Report:

Crash of a Cessna 402C off Treasure Cay: 2 killed

Date & Time: Jul 13, 2003 at 1530 LT
Type of aircraft:
Operator:
Registration:
N314AB
Survivors:
Yes
Schedule:
Fort Lauderdale – Treasure Cay
MSN:
402C-0413
YOM:
1980
Flight number:
RSI502
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
7904
Captain / Total hours on type:
4964.00
Aircraft flight hours:
17589
Circumstances:
On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport (MYAT), Treasure Cay, Great Abaco Island, Bahamas, following the in-flight failure of the right engine. Four of the nine passengers sustained no injuries, three passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 135 as a scheduled international passenger commuter flight from Fort Lauderdale/Hollywood International Airport, Fort Lauderdale, Florida, to MYAT. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules flight plan.
Probable cause:
The in-flight failure of the right engine and the pilotís failure to adequately manage the airplaneís performance after the engine failed. The right engine failure resulted from inadequate maintenance that was performed by Air Sunshine's maintenance personnel during undocumented maintenance. Contributing to the passenger fatalities was the pilotís failure to provide an emergency briefing after the right engine failed.
Final Report:

Crash of a Let L-410UVP-E in San Cristóbal: 4 killed

Date & Time: Jul 13, 2003 at 1415 LT
Type of aircraft:
Registration:
YV-1060CP
Survivors:
Yes
Site:
Schedule:
La Carlota - San Cristóbal
MSN:
90 25 05
YOM:
1990
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
While descending to San Cristóbal Airport, the crew encountered marginal weather conditions and limited visibility due to low clouds. On approach, the twin engine aircraft struck the slope of Mt La Gama located in the Chorro del Indio National Park. Six people were seriously injured while four passengers were killed. The aircraft was destroyed by impact forces.
Probable cause:
Controlled flight into terrain after the crew initiated the descent prematurely in poor visibility.

Crash of a Casa 2.111 in Cheyenne: 2 killed

Date & Time: Jul 10, 2003 at 1310 LT
Type of aircraft:
Operator:
Registration:
N72615
Survivors:
No
Schedule:
Midland – Cheyenne – Missoula
MSN:
124
YOM:
1952
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
21000
Copilot / Total flying hours:
15000
Aircraft flight hours:
1895
Circumstances:
The airplane was en route to an air show and was making a refueling stop. The tower controller cleared the pilot to land. The airplane was observed on a 3-mile straight-in final approach when it began a left turn. The controller asked the pilot what his intentions were. The pilot replied, "We just lost our left engine." The pilot then reported that he wasn't going to make it to the airport. Witnesses observed the airplane flying "low to the ground and under-speed for [a] good 4 minutes." The right propeller was turning, but the left propeller was not turning. There was no fire or smoke coming from the left engine. The pilot was "obviously trying to pull up." The airplane "dipped hard left," then struck the ground left wing first. It slid through a chain link fence, struck a parked automobile, and collided with a school bus wash barn. The ensuing fire destroyed the airplane, parked car, and wash barn. Disassembly and examination of both engines disclosed no anomalies that would have been causal or contributory to the accident. According to the Airplane Flight Manual, "Maximum power will probably be required to maintain flight with one engine inoperative. Maximum power at slow air speed may cause loss of directional control."
Probable cause:
A loss of engine power for reasons undetermined, and the pilot's failure to maintain aircraft control. Contributing factors were the unsuitable terrain on which to make a forced landing, low airspeed, the fence, automobile, and the school bus wash barn.
Final Report:

Crash of a Boeing 737-2J8C in Port Sudan: 116 killed

Date & Time: Jul 8, 2003 at 0417 LT
Type of aircraft:
Operator:
Registration:
ST-AFK
Survivors:
Yes
Schedule:
Port Sudan - Khartoum
MSN:
21169
YOM:
1975
Flight number:
SD139
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
106
Pax fatalities:
Other fatalities:
Total fatalities:
116
Circumstances:
The aircraft departed Port Sudan Airport at 0407LT on a schedule service to Khartoum with 105 passengers and 11 crew members on board. During climbout, the crew informed ATC about technical problems and was cleared to return for an emergency landing on runway 33. On final approach in limited visibility, the aircraft struck the ground and crashed about 5 km from the runway threshold. The aircraft was totally destroyed by impact forces. A boy aged two was injured while 116 other occupants were killed, among them eight EU citizens and one high ranking officer of the Sudan Army.
Probable cause:
Failure of one engine during initial climb for unknown reasons.

Crash of a Cessna 421C Golden Eagle III in Sitka: 5 killed

Date & Time: Jul 3, 2003 at 1600 LT
Operator:
Registration:
N777DX
Flight Type:
Survivors:
No
Site:
Schedule:
Prince Rupert – Anchorage
MSN:
421C-0048
YOM:
1976
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
9200
Aircraft flight hours:
7981
Circumstances:
The pilot of the twin-engine accident airplane was on an IFR flight plan in instrument meteorological conditions when the right side nose baggage door opened. The pilot expressed concerns to air traffic control about baggage exiting the compartment and striking the right propeller. He requested a diversion to the nearest airport with an instrument approach. The flight was diverted as requested, and was cleared for a non precision instrument approach to a coastal airport adjacent to mountainous terrain. The flight was authorized to a lower altitude when established on the approach. A review of the radar track information disclosed that the pilot did not fly the published approach, but abbreviated the approach and turned the wrong direction, toward higher terrain, north of the approach course. The airplane was discovered in mountainous terrain, about 1,100 msl, and 1.5 miles north of the approach course. The crash path was initially at a shallow angle in the treetops, until the airplane struck larger trees. Post accident inspection of the airplane disclosed no evidence of any preimpact mechanical problems, other than the baggage door, which was still attached to the airplane.
Probable cause:
The pilot's failure to follow IFR procedures by not following the published approach procedures, which resulted in an in-flight collision with terrain. Factors contributing to the accident were a low ceiling, and the pressure induced by conditions/events (the open baggage door).
Final Report: