Crash of a Mitsubishi MU-2B-35 Marquise in Belém: 4 killed

Date & Time: Jul 1, 2003 at 1957 LT
Type of aircraft:
Operator:
Registration:
PT-LFX
Survivors:
No
Schedule:
São Luis – Belém
MSN:
650
YOM:
1974
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
11236
Captain / Total hours on type:
4886.00
Copilot / Total flying hours:
1015
Copilot / Total hours on type:
359
Circumstances:
The twin engine aircraft was completing a taxi flight from São Luis to Belém, carrying two passengers, two pilots and a load of briefcases with bank documents. On approach to Belém-Val de Cans Airport by night, the crew encountered poor weather conditions with limited visibility, CB's, rain falls and severe turbulences. On final approach, the aircraft went out of control and crashed on the Ilha das Onças Island, about 5,5 km west of runway 06 threshold. The aircraft was destroyed and all four occupants were killed.
Probable cause:
It was determined that both engines were running normally at impact and no technical anomalies were found on the aircraft and its equipments. Both pilots were properly licenced and experienced on this type of aircraft. At the time of the accident, weather conditions were poor with CB's, rains falls, severe turbulences, strong winds and probable windshear that may have been a contributing factor.
Final Report:

Crash of a Canadair RegionalJet CRJ-100ER in Brest: 1 killed

Date & Time: Jun 22, 2003 at 2351 LT
Operator:
Registration:
F-GRJS
Survivors:
Yes
Schedule:
Nantes - Brest
MSN:
7377
YOM:
2000
Flight number:
AF5672
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
16000
Captain / Total hours on type:
5300.00
Copilot / Total flying hours:
4800
Copilot / Total hours on type:
650
Aircraft flight hours:
6649
Aircraft flight cycles:
6552
Circumstances:
On Sunday 22 June 2003, the CRJ-100 registered F-GRJS was operating as scheduled flight AF 5672 between Nantes Atlantique and Brest-Guipavas aerodromes (France) under an IFR flight plan. The flight represented the last leg of a Brest – Nantes – Strasbourg – Nantes – Brest rotation. The aeroplane was operated by Brit Air on behalf of Air France. The Captain was pilot flying (PF). The crew also included another pilot (the co-pilot), and one cabin crew. The aeroplane took off at 21 h 16 (2) with twenty-one passengers. The flight was approximately fifty minutes late, due to a delay in the first flight of the day that had affected the subsequent flights. During the flight, with the authorisation of the control centre, the crew passed northeast of the planned track in order to avoid cumulonimbus formations. At Brest Guipavas, the 21 h 00 ATIS indicated visibility of eight hundred meters with some fog and a cloud base at two hundred feet with the presence of cumulonimbus. The runway in use was 26 Left with an ILS approach. Runway use was temporarily restricted to Cat I due to presence of works. At 21 h 36 min 27 s, the flight (radio call sign BZ 672 EC) was cleared by the enroute controller to descend to Flight Level 150 then, at 21 h 39 min 10 s, to Flight Level 70. At 21 h 39 min 23 s, the crew announced that they were descending to Flight Level 70 towards BODIL, the initial approach fix, avoiding storms. At 21 h 39 min 31 s, the Brest approach controller transmitted "Descend four thousand feet QNH one thousand and eight, number two on approach, plan a holding pattern at Golf Uniform". At 21 h 44 min 21 s, the controller cleared descent to three thousand feet and added "and perform a holding pattern". The aeroplane was approximately 20 NM DME from BG. At 21 h 47 min 40 s, that is, approximately one-and-a-half-minutes before the planned start of the hold, the controller cleared descent to two thousand feet QNH. At 21 h 48 min 01 s, the controller announced "Echo Charlie, preceding aeroplane has landed, continue the approach, report at Outer Marker". Four seconds later, at 9.4 NM DME, the autopilot "Heading" and "Vertical Speed" modes became active and the aeroplane adopted a heading of 257°. The Brest ILS frequency was displayed on the VOR 1 and the VOR navigation source was selected. At 21 h 48 min 21 s, the controller called back "Are you ready for the approach?". The crew confirmed and the controller asked "Report at Outer Marker". The Copilot read this back. At the Captain’s request, the Co-pilot extended the flaps to 20° then the landing gear. The aeroplane stabilized at two thousand feet QNH on autopilot, still in Heading mode, at about 7 NM DME. Simultaneously, the wind, which had started to veer northwest during the descent, caused the aeroplane to drift towards the left. The flight crew did not notice this drift. At 21 h 49 min, the co-pilot extended the flaps to 30° then to 45° and the crew performed the pre-landing checklist. At 21 h 49 min 35 s, the controller cleared the landing for runway 26 Left and indicated a cloud base of less than one hundred feet. At 21 h 49 min 40 s, the aeroplane, in level flight, passed under then above the glide slope. At 21 h 50 min, the aeroplane passed the GU beacon, slightly to the left, with a track deviating to the left in relation to the localizer centreline. At that moment, the wind calculated by the Flight Management System (FMS) was 300° / 20 kt. A short time later, the aeroplane began its descent. The aeroplane continued to drift to the left of the localizer centreline. At 21 h 50 min 45 s the aeroplane again passed through the glide slope, and the Captain said "Approach selected, LOC and Glide"; the Co-pilot confirmed. The autopilot "heading" and "vertical speed" modes remained active. The aeroplane thereafter remained below the glide slope for the remainder of the flight. Between 21 h 50 min 58 s and 21 h 51 min 02 s, the GPWS announced, successively, "Five hundred", "Glide slope" then "Sink rate". At 21 h 51 min 01 s, the aeroplane began a turn to the right. By this time, the aeroplane was 4.68 points to the left of the localizer centreline. At 21 h 51 min 04 s, the Captain disengaged the autopilot. At 21 h 51 min 05 s, the GPWS announced "Three hundred". Between 21 h 51 min 07 s and 21 h 51 min 14 s, seven "Glide slope" alarms sounded. During this time, the Co-pilot said "come right" on two occasions and the aeroplane attitude changed from - 5° to 0°. At 21 h 51 min 15 s, the GPWS announced "One hundred". At 21 h 51 min 16 s, with the aeroplane at 529 feet QNH and 93 feet on the radio altimeter, the Co-pilot said "I’ve got nothing in front", then the Captain said "Go around". Simultaneously, the engine thrust increased significantly. The aeroplane attitude returned to - 5 in four seconds. At 21 h 51 min 19 s, the Co-pilot said "Go around". At 21 h 51 min 20 s, the GPWS announced "Sink rate" then "Pull up". The Co-pilot said "Go around" again at 21 h 51 min 22. The first sounds of the impact were recorded by the CVR at 21 h 51 min 22 s, and the recording stopped at 21 h 51 min 24. s. The aeroplane, which touched the ground without any great force, rolled, struck several obstacles and ended up 450 meters left of the extended runway centreline, 2,150 meters from the runway threshold. The Captain was killed. The rest of the crew and the passengers managed to evacuate the aeroplane, which was destroyed by fire.
Probable cause:
The causes of the accident are as follows:
• neglecting to select the APPR mode at the start of the approach, which led to non-capture of the localizer then of the glide slope;
• partial detection of flight path deviations, due to the crew’s focusing on vertical navigation then on horizontal navigation;
• continuing a non-stabilised approach down to the decision altitude.
Lack of communication and coordination in the cockpit, and a change of strategy on the part of the Controller in managing the flight were contributing factors.
Final Report:

Crash of a Cessna 402B in Little Whale Cay

Date & Time: Jun 17, 2003 at 1330 LT
Type of aircraft:
Registration:
N3748C
Survivors:
Yes
Schedule:
Chub Cay - Little Whale Cay
MSN:
402B-0606
YOM:
1974
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 17, 2003, about 1330 eastern daylight time, a Cessna 402B, N3748C, registered to Hamilton Development Company Ltd., operated by Execstar Aviation, Inc., collided with a seawall during the landing roll at a private airstrip located on Little Whale Cay, Bahamas. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 135 non-scheduled, international, passenger/cargo flight. The airplane was substantially damaged and the commercial-rated pilot and two passengers were not injured. The flight originated about 10 minutes earlier from Chub Cay, Bahamas. The pilot stated that after takeoff the flight proceeded to the destination airport where he overflew the runway and set up for landing to the southeast on the 2,000 foot-long runway. While on final approach with the flaps fully extended, he maintained 95 knots which was just below blue line, then slowed to 88 knots when the runway was assured. He landed within the first 1/3 on the wet runway and reported inadequate braking and the airplane was possibly hydroplaning. Recognizing that he was unable to clear an approximately 4-foot-tall seawall near the end of the runway, he applied aft elevator control input. He further stated he believes the main landing gear contacted the seawall causing them to structurally separate. The airplane descended and impacted the water where he and the passengers exited the airplane using the emergency window and walked to the beach.

Crash of a Fokker 50 in Adar Yeil

Date & Time: Jun 16, 2003 at 0630 LT
Type of aircraft:
Operator:
Registration:
ST-ARA
Survivors:
Yes
Schedule:
Khartoum - Adar Yeil
MSN:
20154
YOM:
1989
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
42
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on a gravel runway at Adar Yeil Airport, the aircraft collided with a flock of birds, damaging the left engine. The aircraft went out of control and veered to the left, causing the left propeller to struck the ground. The propeller blades separated, punctured the fuselage and injured three passengers. The aircraft came to a halt and all occupants evacuated. The aircraft was damaged beyond repair.
Probable cause:
Loss of control after landing following a collision with a flock of birds.

Crash of an Antonov AN-24RV in Nueva Gerona

Date & Time: Jun 14, 2003 at 1605 LT
Type of aircraft:
Operator:
Registration:
CU-T1295
Survivors:
Yes
Schedule:
Nueva Gerona - Havana
MSN:
2 73 075 08
YOM:
1972
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
48
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After takeoff from Nueva Gerona-Rafael Cabrera Airport runway 23, the crew elected to climb to an altitude of 1,000 feet he encountered technical problems. He contacted ATC and was cleared for an immediate return. Following a 180 turn, the crew completed a flapless approach to runway 05. After landing, the aircraft rolled for about 2,500 metres then overran and came to rest in an artificial lake. All 52 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Failure of the hydraulic systems after takeoff for unknown reasons.

Crash of an Antonov AN-32B in Jaffna

Date & Time: Jun 14, 2003
Type of aircraft:
Operator:
Registration:
CR-866
Flight Type:
Survivors:
Yes
Schedule:
Colombo - Jaffna
MSN:
36 01
YOM:
1996
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
50
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Jaffna-Palaly Airport, the aircraft went out of control and veered off runway. It collided with a signpost, injured one soldier on the ground and came to rest. All 55 occupants escaped uninjured but the aircraft was damaged beyond repair.

Crash of an Embraer EMB-820C Navajo in Belo Horizonte: 4 killed

Date & Time: Jun 11, 2003 at 1600 LT
Registration:
PT-EHH
Survivors:
No
Schedule:
Belo Horizonte – Juiz de Fora
MSN:
820-044
YOM:
1977
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
180
Copilot / Total flying hours:
150
Circumstances:
The twin engine aircraft departed Belo Horizonte-Pampulha Airport at 1522LT on a taxi flight to Juiz de Fora, carrying two pilots, two passengers and a load of valuables. While cruising about 35 nm south of Belo Horizonte, the crew encountered technical problems with the engines and elected to return for an emergency landing. On approach to runway 13, the aircraft was too high and the crew was cleared to make a 360 turn to reduce his altitude. Doing so and after he completed 270° of this turn, the aircraft entered an uncontrolled descent and crashed 2 km short of runway, bursting into flames. The aircraft was totally destroyed by impact forces and a post crash fire and all four occupants were killed.
Probable cause:
The right engine suffered a oil leak in flight following the failure of a hose due to poor maintenance. The following contributing factors were identified:
- Both pilots did not have sufficient experience nor training on this type of aircraft,
- The copilot was flying for this operator for the first time,
- The operator was unable to provide any maintenance documentation nor crew training documentation to investigators,
- Both engines were running at impact but with limited power,
- The right propeller was feathered at impact.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Christchurch: 8 killed

Date & Time: Jun 6, 2003 at 1907 LT
Registration:
ZK-NCA
Survivors:
Yes
Schedule:
Palmerston North – Christchurch
MSN:
31-7405203
YOM:
1974
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
4325
Captain / Total hours on type:
820.00
Aircraft flight hours:
13175
Circumstances:
The aircraft was on an air transport charter flight from Palmerston North to Christchurch with one pilot and 9 passengers. At 1907 it was on an instrument approach to Christchurch Aerodrome at
night in instrument meteorological conditions when it descended below minimum altitude, in a position where reduced visibility prevented runway or approach lights from being seen, to collide with trees and terrain 1.2 nm short of the runway. The pilot and 7 passengers were killed, and 2 passengers received serious injury. The aircraft was destroyed. The accident probably resulted from the pilot becoming distracted from monitoring his altitude at a critical stage of the approach. The possibility of pilot incapacitation is considered unlikely, but cannot be ruled out.
Probable cause:
Findings:
- The pilot was appropriately licensed and rated for the flight.
- The pilotís previously unknown heart disease probably would not have made him unfit to hold his class 1 medical certificate.
- The pilotís ability to control the aircraft was probably not affected by the onset of any incapacitation associated with his heart condition.
- Although the pilot was experienced on the PA 31 type on VFR operations, his experience of IFR operations was limited.
- The pilot had completed a recent IFR competency assessment, which met regulatory requirements for recent instrument flight time.
- The aircraft had a valid Certificate of Airworthiness, and the scheduled maintenance which had been recorded met its airworthiness requirements.
- The return of the cabin heater to service by the operator, after the maintenance engineer had disabled it pending a required test, was not appropriate but was not a factor in the accident.
- The cabin heater was a practical necessity for IFR operations in winter, and the required test should have been given priority to enable its safe use.
- The 3 unserviceable avionics instruments in the aircraft did not comply with Rule part 135, and indicated a less than optimum status of avionics maintenance. However there was sufficient
serviceable equipment for the IFR flight.
- The use of cellphones and computers permitted by the pilot on the flight had the potential to cause electronic interference to the aircraftís avionics, and was unsafe.
- The pilotís own cellphone was operating during the last 3 minutes of the flight, and could have interfered with his glide slope indication on the ILS approach.
- The aircraftís continued descent below the minimum altitude could not have resulted from electronic interference of any kind.
- The pilotís altimeter was correctly set and displayed correct altitude information throughout the approach.
- There was no aircraft defect to cause its continued descent to the ground.
- The aircraftís descent which began before reaching the glide slope, and continued below the glide slope, resulted either from a faulty glide slope indication or from the pilot flying a localiser approach instead of an ILS approach.
- When the aircraft descended below the minimum altitude for either approach it was too far away for the pilot to be able to see the runway and approach lights ahead in the reduced visibility at the time.
- The pilot allowed the aircraft to continue descending when he should have either commenced a missed approach or stopped the aircraftís descent.
- The pilotís actions or technique in flying a high-speed unstabilised instrument approach; reverting to hand-flying the aircraft at a late stage; not using the autopilot to fly a coupled approach and, if intentional, his cellphone call, would have caused him a high workload and possibly overload and distraction.
- The pilotís failure to stop the descent probably arose from distraction or overload, which led to his not monitoring the altimeter as the aircraft approached minimum altitude.
- The possibility that the pilot suffered some late incapacity which reduced his ability to fly the aircraft is unlikely, but cannot be ruled out.
- If TAWS equipment had been installed in this aircraft, it would have given warning in time for the pilot to avert the collision with terrain.
- While some miscommunication of geographical coordinates caused an erroneous expansion of the search area, the search for the aircraft was probably completed as expeditiously as possible in difficult circumstances.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Anchorage

Date & Time: Jun 6, 2003 at 1705 LT
Type of aircraft:
Registration:
N343WB
Flight Type:
Survivors:
Yes
Schedule:
Beluga - Anchorage
MSN:
999
YOM:
1956
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
6860
Captain / Total hours on type:
1711.00
Aircraft flight hours:
5698
Circumstances:
The float-equipped airplane was in the traffic pattern to land at a seaplane base when the engine lost all power, and the pilot made an emergency landing in the backyard of a private residence. During the forced landing, the airplane struck trees and a railing on the deck of the residence, sustaining structural damage to the left wing. The pilot reported that he had the right wing fuel tank selected, and thought the tank was about 1/4 full. He indicated that when the engine lost power, he was too low and didn't have sufficient time or altitude to switch to the belly tank and restore power. Postaccident draining of the fuel tanks disclosed about 18 gallons of fuel in the belly tank, and about one quart in the right wing tank.
Probable cause:
The pilot's incorrect positioning of the fuel tank selector to a nearly empty tank, which resulted in a loss of engine power due to fuel starvation, and subsequent emergency landing at an off airport site.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Lake Wicksteed

Date & Time: Jun 5, 2003 at 1800 LT
Operator:
Registration:
C-GOGC
Flight Type:
Survivors:
Yes
MSN:
750
YOM:
1981
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
22000
Captain / Total hours on type:
8500.00
Circumstances:
The aircraft with a single pilot on board was performing firefighting operations in the vicinity of Lake Wicksteed, approximately 10 nautical miles north of Hornepayne, Ontario. The aircraft was scooping water from Lake Wicksteed for the nearby fire. The lake is approximately 7300 feet in length with gentle rising terrain along its shoreline. This was the third scooping from the lake, and the approach was flown in an easterly direction in light wind conditions. The pilot performed the inbound checks, lowered the water probes to begin filling the float water tanks, and touched down on the lake. Within a short time, he observed water spraying from the overflow vents located on top of the floats, indicating that the tanks were filled to capacity. He pressed a button on the yoke to retract the probes, and the aircraft immediately nosed over into the lake in a wings-level attitude and began to sink. The accident occurred at approximately 1800 eastern daylight time. The pilot extricated himself from the aircraft and held on to the side of the partially submerged aircraft. A witness to the occurrence immediately boarded a powered, aluminum boat and went to assist the pilot, while a second witness travelled to Hornepayne to notify the authorities and emergency services. Once the pilot reached the shore, he was taken to a nearby cottage where he remained until emergency services arrived. The aircraft came to rest on the bottom of the shallow lake in an inverted attitude with the floats above the surface of the water.
Probable cause:
Findings as to Causes and Contributing Factors:
1. Ministry of Natural Resources DHC-6 SOPs were not followed, and the Vital Action checklist was not fully completed during the approach. As a result, the bomb door armed switch on the centre panel was not selected Off after the previous water bombing run and prior to the scooping operation.
2. After completing the water scooping operation, the pilot unintentionally selected the bomb door push button switch instead of the adjacent probe switch. Because the bomb door armed switch on the centre panel was left On, the bomb doors extended into the water. Drag from the doors and the water rushing into the door openings resulted in the aircraft nosing over in the water.
3. The hinged cover plate for the bomb door push button switch was not re-installed following maintenance to replace the push button switch. The push button was exposed, making an inadvertent selection more likely.
Final Report: