Crash of a Fokker F28 Fellowship 1000 near Chachapoyas: 46 killed

Date & Time: Jan 9, 2003 at 0845 LT
Type of aircraft:
Operator:
Registration:
OB-1396
Survivors:
No
Site:
Schedule:
Lima – Chiclayo – Chachapoyas
MSN:
11100
YOM:
1975
Flight number:
TJ222
Country:
Crew on board:
5
Crew fatalities:
Pax on board:
41
Pax fatalities:
Other fatalities:
Total fatalities:
46
Captain / Total flying hours:
3127
Captain / Total hours on type:
753.00
Copilot / Total flying hours:
9255
Copilot / Total hours on type:
1065
Aircraft flight hours:
13121
Circumstances:
The aircraft departed Lima on a regular schedule flight to Chachapoyas with an intermediate stop in Chiclayo, carrying 41 passengers and five crew members. Following an uneventful flight from Chiclayo, the crew started the descent to Chachapoyas Airport in poor weather conditions. The crew maintained several radio contacts with ATC and all seemed to be 'normal' on board when the aircraft struck the slope of Mt Coloque located 15 km from the airport. Due to poor weather conditions and because the crash site was unaccessible, SAR teams arrived on scene two days later. The wreckage was found at an altitude of 3,300 metres. The aircraft disintegrated on impact and all 46 occupants were killed. The occupants were respectively 41 Peruvians, two Belgians, one Dutch, one Spanish and one Cuban.
Probable cause:
It was determined that the accident was the consequence of a controlled flight into terrain after the crew continued the descent in zero visibility after suffering a total loss of situational awareness. The following contributing factors were identified:
- The crew failed to proceed with an approach briefing,
- Overconfidence on part of the flying crew,
- The crew failed to follow the approach checklist,
- The crew failed to comply with the SOP's,
- Poor crew resources management,
- The copilot was tired, stressed and depressive because his father passed away four days prior to the accident,
- The crew was destabilized by a certain pressure from the operator's,
- Poor judgment on part of the flying crew,
- Poor approach planning,
- Inadequate monitoring,
- Poor visual perception,
- Operational complacency,
- The crew was non-compliant with published procedures,
- Disorientation and loss of situational awareness.
Final Report:

Crash of an Avro RJ100 in Diyarbakir: 75 killed

Date & Time: Jan 8, 2003 at 2019 LT
Type of aircraft:
Operator:
Registration:
TC-THG
Survivors:
Yes
Schedule:
Istanbul – Diyarbakir
MSN:
E3241
YOM:
1994
Flight number:
TK634
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
75
Pax fatalities:
Other fatalities:
Total fatalities:
75
Captain / Total flying hours:
6309
Captain / Total hours on type:
473.00
Copilot / Total flying hours:
2052
Copilot / Total hours on type:
1802
Aircraft flight hours:
19289
Aircraft flight cycles:
16659
Circumstances:
On final approach to Diyarbakir Airport by night, the crew encountered marginal weather conditions with local patches of fog and limited visibility. On short final, in a slight nose down attitude, the aircraft struck the ground and crashed 900 metres short of runway 34, bursting into flames. Five passengers were seriously injured while 75 other occupants were killed. At the time of the accident, the crew was completing a VOR/DME approach to runway 34 that was not equipped with an ILS.
Probable cause:
It was determined that the crew established a visual contact with the runway lights when, on short final, due to the presence of local patches of fog, the pilot-in-command lost visual contact with the ground for few seconds. This caused the aircraft to descend below the MDA until it impacted the ground 900 metres short of runway threshold. Poor weather conditions were considered as a contributing factor.
Final Report:

Crash of a Raytheon 390 Premier I in Santo Domingo

Date & Time: Jan 8, 2003 at 1824 LT
Type of aircraft:
Registration:
N390RB
Survivors:
Yes
Schedule:
Santo Domingo - Santo Domingo
MSN:
RB-26
YOM:
2002
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft overran the runway and came to rest in a parking lot, while landing at Herrera International Airport, Santo Domingo, Dominican Republic, while on a 14 CFR Part 91 positioning flight. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed. The airplane received substantial damage and the airline transport-rated pilot, copilot, and two passengers received minor injuries. The flight originated from Las Americas International Airport, Santo Domingo, Dominican Republic, the same day, about 1810. The pilot stated they made a normal approach and landing on runway 19 at Herrera International Airport. Once on the ground they activated lift dump spoilers, but the system failed. They were unable to stop the airplane on the remaining runway. The airplane came to a stop, inverted beyond a street that is at the end of the runway.

Crash of a Piper PA-46-500TP Malibu Meridian in Dunkeswell

Date & Time: Dec 31, 2002 at 1749 LT
Registration:
N961JM
Survivors:
Yes
Schedule:
Chambéry – Dunkeswell
MSN:
46-97122
YOM:
2002
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8899
Captain / Total hours on type:
2095.00
Circumstances:
The pilot was carrying out an IFR flight from Chambery in France to Dunkeswell Aerodrome using Exeter Airport as his diversion. Before departure from Chambery he had checked the weather conditions at Exeter and other airfields in its vicinity from the available TAFs and METARs covering the period of the flight and he was satisfied that conditions were suitable. He had also contacted a friend who was also a commercial pilot at about 1530 hrs. This friend lived near Dunkeswell Aerodrome and had estimated the cloud base to be approximately 1,500 feet. The aircraft departed Chambery at 1605 hrs and, apart from some airframe icing on departure, it had an uneventful transit at FL270. Approaching the south coast of England, the aircraft was descended to FL60 and it left controlled airspace at Southampton in good VMC with the lights along the south coast clearly visible. The weather at Exeter at 1720 hrs was: surface wind 130°/08 kt, varying between 110° and 170°; visibility 6,000 metres; cloud SCT 005, BKN 012; temperature +9° C; dew point +8° C and QNH 1011 mb. With approximately 50 miles to run to his destination, the pilot attempted to contact Dunkeswell Radio but received no reply so he assumed the airfield had closed for the night. The lights of Dunkeswell village and the industrial site at the north-eastern edge of the aerodrome were visible but they had a milky appearance as if shining through scattered mist pockets. The aircraft was descended to 2,600 feet on the Exeter QNH and the main altimeter was set to the Dunkeswell QFE by subtracting 31 mb from the Exeter QNH to allow for the Dunkeswell elevation of 850 feet. The pilot was utilising two GPS navigation systems programmed to provide him with centreline information for Runway 23 on a CDI (Course Deviation Indicator) scale of 0.3 nm for full deflection. Whilst there was no runway lighting at Dunkeswell, the pilot had placed white reflective panels on the right edge of Runway 23. When illuminated by the aircraft landing light, these panels would show the right hand edge of the runway and also indicate the touchdown zone of the runway. The panels measured 18 cm by 9.5 cm and were mounted vertically on low, black plastic supports. The threshold for Runway 23 is displaced 290 metres from the road which runs along the northern aerodrome boundary and the first reflector was 220 metres beyond the displaced threshold. The reflectors had been positioned over a distance of 460 metres with the distances between them varying between 15 and 49 metres. The white centreline markings would also have been visible in the landing light once the aircraft was low enough. The end of the 46 metre wide runway was 280 metres from the last reflector. The pilot had carried out night approaches and landings to Runway 23 at Dunkeswell using similar visual references on many previous occasions. The pilot identified the lights of the industrial site earlier than he expected at six miles whilst maintaining 2,600 feet on the Exeter QNH. He cancelled his radar service from Exeter, which had also provided him with ranges and bearings from Dunkeswell, and made blind transmissions regarding his position and intentions on the Dunkeswell Radio frequency. Having commenced his final approach, the pilot noticed there was scattered cloud in the vicinity of the approach path. At about 2.5 nm from the runway threshold and approximately 800 feet agl, the pilot noticed a mist pocket ahead of the aircraft and so he decided to initiate a go-around and divert to Exeter. At that point the aircraft was configured with the second stage of flap lowered, the landing gear down and the airspeed reducing through 135 kt with all three aircraft landing lights selected ON. The pilot increased power and commenced a climb but he became visual with the runway once more and so he reduced power and resumed the approach. A high rate of descent developed and the radio altimeters automatic 50 feet audio warning sounded. The pilot started to increase engine power but he was too late to prevent the severe impact with terrain that followed almost immediately. The aircrafts wings were torn off as it passed between two trees and the fuselage continued across a grass field, remaining upright until it came to a stop. The passenger vacated the aircraft immediately through the normal exit in the passenger cabin and then returned to assist the pilot. Having turned off the aircraft's electrical and fuel systems the pilot also left the aircraft through the normal exit. There was a leak from the oxygen system, which had been disrupted in the accident and the pilot was unable to remove the fire extinguisher from its stowage due to the deformation of the airframe. He contacted Exeter ATC using his mobile telephone to inform them of the accident and they initiated the response of the emergency services.
Probable cause:
The investigation concluded that the accident had occurred due to an attempt to land at night in fog, at an airfield with no runway lighting and only limited cultural lighting to provide visual
orientation; these visual references were lost when the fog was entered. The aircraft impacted the treeline at the top of the valley 1,600 metres short of the displaced threshold and 200 metres to the right of the centreline.
Final Report:

Crash of an Embraer EMB-110P1 Bandeirante in Freetown

Date & Time: Dec 31, 2002
Registration:
9L-LBR
Survivors:
Yes
Schedule:
Freetown - Freetown
MSN:
110-411
YOM:
1982
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was performing a flight from Freetown-Lungi Airport to Freetown-Hastings located southeast of the capital city. During the night, rebels sabotaged the runway with concrete and steel projectiles. After landing, the right main gear struck several obstructions and was torn off. The aircraft came to rest and was damaged beyond repair while all 16 occupants escaped uninjured. The exact date of the mishap remains unknown, somewhere in 2002.

Crash of a De Havilland DHC-3 Otter in Nikolai

Date & Time: Dec 28, 2002 at 1230 LT
Type of aircraft:
Registration:
N3904
Flight Type:
Survivors:
Yes
Schedule:
Nikolai – Wasilla
MSN:
54
YOM:
1954
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4000
Captain / Total hours on type:
400.00
Aircraft flight hours:
16437
Circumstances:
The commercial certificated pilot reported that just after takeoff in a wheel/ski equipped airplane, he heard a very loud bang, followed by a loud rattling noise. As he turned towards the departure airstrip, he had difficulty using the airplane's rudder pedals. Using a combination of aileron input and the remaining amount of rudder control, he was able to maneuver the airplane for a landing on the airstrip. He said that as the airplane passed over the approach end of the airstrip, it drifted to the right, and he initiated a go-around. The airplane subsequently collided with a stand of trees bordering the airstrip, and sustained structural damage to the wings, fuselage, and empennage. In a written statement to the NTSB, the pilot stated that he suspected that the right elevator's outboard and center hinges or hinge pins failed, allowing the right elevator to swing rearward and jam the airplane's rudder. An FAA airworthiness inspector traveled to the accident scene to examine the airplane. He reported that the right elevator was discovered about 150 feet behind the airplane, within the wreckage debris path through a stand of trees. He said that the right elevator sustained a significant amount of damage along the leading edge, which would normally be protected by the horizontal stabilizer. The FAA inspector examined the airplane's horizontal stabilizer in the area where the right and left elevators connect, and noted signs of new paint on the rivets that held the torque tube support assembly, indicating recent reinstallation or replacement of the torque tube support assembly. He indicated that the torque tube support assembly was installed at a slight angle to the right, which allowed the right elevator to eventually slip off of the center and outboard hinge pins. The inspector said that witness marks on the center and outboard hinge pins showed signs of excessive wear towards the outboard portion of each pin. The inspector noted that a review of the airplane's maintenance records failed to disclose any entries of repair/replacement of the elevator torque tube support assembly.
Probable cause:
An improper and undocumented major repair of the elevator torque tube support assembly by an unknown person, which resulted in an in-flight disconnection of the airplane's right elevator, and a jammed rudder. A factor associated with the accident is the inadequate inspection of the airplane by company maintenance personnel.
Final Report:

Crash of a Let L-410UVP in Mutsamudu: 1 killed

Date & Time: Dec 27, 2002 at 1215 LT
Type of aircraft:
Registration:
9XR-RB
Survivors:
Yes
Schedule:
Moroni - Mutsamudu
MSN:
81 06 36
YOM:
1981
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While approaching Mutsamudu Airport, the crew encountered poor weather conditions with thunderstorm activity and heavy rain falls. The crew followed a holding pattern about 30 km away from the airport for weather improvement. Few minutes later, the crew started the descent to Mutsamudu-Ouani Airport. On approach at an altitude of 2,500 feet, the aircraft was struck by lightning. The crew elected to initiate a go-around procedure but the electrical system partially failed due to lightning and both gyro compasses and artificial horizons failed. Control was lost and the aircraft crashed in a wooded area located few km from the airport. A passenger was killed while 15 other occupants were injured.

Crash of an Antonov AN-26B in Ust-Kuyga

Date & Time: Dec 27, 2002
Type of aircraft:
Operator:
Registration:
RA-26053
Flight Type:
Survivors:
Yes
Schedule:
Yakutsk - Ust-Kuyga
MSN:
109 09
YOM:
1981
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
17609
Aircraft flight cycles:
9649
Circumstances:
Following an uneventful cargo flight from Yakutsk, the crew started the approach to Ust-Kuyga on a polar night with an OAT of -51° C. On final approach, at a distance of 1,150 metres from the runway threshold, the aircraft deviated to the right by 150 metres. The captain was instructed by ATC to initiate a go-around but he decided to continue the approach. Unstable, the aircraft's speed dropped to 210 km/h and on the last segment, it lost height, causing the right main gear to struck the runway surface. On impact, the right main gear was torn off, followed shortly later by the nose gear. Out of control, the aircraft slid for few dozen metres before coming to rest. All six occupants escaped uninjured and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Wrong approach configuration on part of the crew,
- The aircraft was unstable on approach,
- The approach' speed of 210 km/h was insufficient (20 km/h below the prescribed speed),
- On the last segment, the aircraft rolled to the right following improper actions from the crew,
- The crew failed to initiate a go-around and ignored ATC instructions,
- The configuration adopted by the crew resulted in the aircraft making a deliberate descent to the right of the approach pattern.

Crash of an Embraer C-95A Bandeirante in Curitiba: 3 killed

Date & Time: Dec 26, 2002 at 1120 LT
Type of aircraft:
Operator:
Registration:
2292
Flight Type:
Survivors:
Yes
Schedule:
São Paulo – Florianópolis – Porto Alegre
MSN:
110-174
YOM:
1978
Country:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The twin engine aircraft departed Campo de Marte AFB near São Paulo on a flight to Porto Alegre with an intermediate stop in Florianópolis, carrying 13 passengers and three crew members. En route to Florianópolis, while in cruising altitude, the crew encountered technical problems, declared an emergency and was cleared to divert to Curitiba-Afonso Pena Airport. On final approach to runway 33, the aircraft stalled and crashed in a grassy area located 3,600 metres short of runway. Two passengers and one pilot were killed while 13 other occupants were injured.
Probable cause:
Double engine failure caused by a fuel exhaustion. It was determined that the crew did not prepare the flight according to procedures and took off with an insufficient fuel quantity on board.

Crash of a Cessna 421A Golden Eagle I in Akron: 2 killed

Date & Time: Dec 25, 2002 at 1006 LT
Type of aircraft:
Registration:
N421D
Flight Type:
Survivors:
No
Schedule:
Denver - Mitchell
MSN:
421A-0045
YOM:
1967
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1230
Captain / Total hours on type:
22.00
Aircraft flight hours:
3564
Circumstances:
The pilot reported to Denver Air Route Traffic Control Center (ZDV) that his left engine had an oil leak and he requested to land at the nearest airport. ZDV informed the pilot that Akron (AKO) was the closest airport and subsequently cleared the pilot to AKO. On reporting having the airport in sight ZDV terminated radar service, told the pilot to change to the advisory frequency, and reminded him to close his flight plan. Approximately 17 minutes later, ZDV contacted Denver FSS to inquire if the airplane had landed at AKO. Flight Service had not heard from the pilot, and began a search. Approximately 13 minutes later, the local sheriff found the airplane off of the airport. Witnesses on the ground reported seeing the airplane flying westbound. They then saw the airplane suddenly pitch nose down, "spiral two times, and crash." The airplane exploded on impact and was consumed by fire. An examination of the airplane's left engine showed the number 2 and 3 rods were fractured at the journals. The number 2 and 3 pistons were heavily spalded. The engine case halves were fretted at the seam and through bolts. All 6 cylinders showed fretting between the bases and the case at the connecting bolts. The outside of the engine case showed heat and oil discoloration. The airplane's right engine showed similar fretting at the case halves and cylinder bases, and evidence of oil seepage around the seals. It also showed heat and oil discoloration. An examination of the propellers showed that both propellers were at or near low pitch at the time of the accident. The examination also showed evidence the right propeller was being operated under power at impact, and the left propeller was operating under conditions of low or no power at impact. According to the propeller manufacturer, in a sudden engine seizure event, the propeller is below the propeller lock latch rpm. In this situation, the propeller cannot be feathered. Repair station records showed the airplane had been brought in several times for left engine oil leaks. One record showed a 3/4 inch crack found at one of the case half bolts beneath the induction manifold, was repaired by retorquing the case halves and sealing the seam with an unapproved resin. Records also showed the station washed the engine and cowling as the repair action for another oil leak.
Probable cause:
The fractured connecting rods and the pilot not maintaining aircraft control following the engine failure. Factors contributing to the accident were the low altitude, the pilot not maintaining minimum controllable airspeed following the engine failure, the pilot's inability to feather the propeller following the engine failure, oil exhaustion, the seized pistons, and the repair station's improper maintenance on the airplane's engines.
Final Report: