Crash of a Cessna 550 Citation II in Sandspit

Date & Time: Nov 12, 2002 at 2052 LT
Type of aircraft:
Operator:
Registration:
C-GYCJ
Flight Type:
Survivors:
Yes
Schedule:
Vancouver - Sandspit
MSN:
550-0561
YOM:
1987
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4550
Captain / Total hours on type:
1450.00
Copilot / Total flying hours:
3300
Copilot / Total hours on type:
850
Circumstances:
The aircraft departed Vancouver International Airport, British Columbia, on a medical evacuation flight to the Sandspit Airport in the Queen Charlotte Islands, British Columbia. On board the aircraft were two pilots and a team of two Advanced Life Support Paramedics. When the aircraft arrived at Sandspit, the surface wind was strong, gusty, and across the runway. The crew conducted an instrument approach to Runway 30, and just before touchdown the aircraft's nose pitched down; the captain believed that the nosewheel, and then the main gear, collapsed as the aircraft slid on its belly. The crew carried out an evacuation and proceeded to the airport terminal building. When they returned to the aircraft to retrieve their belongings, the crew discovered that the gear was in the up position, as was the landing gear selector. The accident occurred at 2052 Pacific standard time. There were no injuries. The aircraft was substantially damaged.
Probable cause:
Findings as to causes and contributing factors:
1. The crew did not complete the before-landing checks, ignored aural warnings, and did not lower the landing gear, which resulted in a gear-up landing.
Findings as to risk:
1. The aircraft was not equipped with a GPWS, which could have prevented this accident.
2. The before-landing checklist in use did not reflect the AFM requirement that the speed brakes should be retracted prior to 50 feet.
Final Report:

Crash of an Antonov AN-26B in Antalya

Date & Time: Nov 9, 2002 at 1900 LT
Type of aircraft:
Operator:
Registration:
RA-26012
Survivors:
Yes
Site:
Schedule:
Asmara – Port Sudan – Hurghada – Antalya
MSN:
100 07
YOM:
1980
Flight number:
TMN9012
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft was completing a charter flight from Asmara to Antalya with intermediate stops in Port Sudan and Hurghada, carrying helicopter crews back in Russia. On approach to Antalya by night, the crew was informed about the poor weather conditions at destination with thunderstorm activity, visibility limited to two km, wind from 220 gusting at 35 knots. ATC advised the crew to maintain heading and to initiate a go-around in case they would not establish a visual contact with the runway. On short final, the left engine struck a 10 metres high electric pole. The aircraft lost height and crashed on a road located 1,325 metres short of runway and 550 metres to the left of its extended centerline. All 27 occupants were rescued, among them eight were injured. The aircraft was destroyed.
Probable cause:
The following findings were identified:
- The crew mistook the road lights for the airport lights and descended to low,
- The crew continued the approach after passing the MDA,
- The crew failed to initiate a go-around procedure,
- Limited visibility due to poor weather conditions,
- Some ATC instructions lead to confusion,
- Informations related to weather condition were inaccurate.

Crash of an IAI 1124A Westwind II in Taos: 2 killed

Date & Time: Nov 8, 2002 at 1457 LT
Type of aircraft:
Operator:
Registration:
N61RS
Flight Type:
Survivors:
No
Schedule:
Las Vegas - Taos
MSN:
384
YOM:
1983
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5251
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
14234
Copilot / Total hours on type:
682
Aircraft flight hours:
3428
Circumstances:
After passing the initial approach fix, during an instrument approach to the destination airport, radar and radio contact were lost with the business jet. One witness reported hearing "distressed engine noises overhead," and looked up and saw what appeared to be a small private jet flying overhead. The engine seemed to be "cutting in and out." The witness further reported observing the airplane in a left descending turn until his view was blocked by a ridge. The witness then heard an explosion and saw a big cloud of smoke rising over the ridge. A second witness heard a loud noise and looked up and saw a small white airplane with two engines. The witness stated that the airplane started to turn left with the nose of the airplane slightly pointing toward the ground. The airplane appeared to be trying to land on a road. A third witness heard the roar of the airplane's engines, and looked toward the noise and observed the airplane in a vertical descent (nose dive) impact the ground. The witness "heard the engines all the way to the ground." Examination of the airframe and engines did not disclose any structural or mechanical anomalies that would have prevented normal operation. The National Weather Service had issued a SIGMET for severe turbulence and mountain wave activity. Satellite images depicted bands of altocumulus undulates and/or rotor clouds over the accident site.
Probable cause:
The pilot's inadvertent flight into mountain wave weather conditions while IMC, resulting in a loss of aircraft control.
Final Report:

Crash of a Cessna 207 Skywagon in Cradle Mountain

Date & Time: Nov 7, 2002 at 1404 LT
Registration:
VH-EHL
Flight Type:
Survivors:
Yes
Schedule:
Cradle Mountain - Cradle Mountain
MSN:
207-0141
YOM:
1970
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
730
Captain / Total hours on type:
180.00
Circumstances:
The Cessna 207 aircraft (C207) was engaged on a sightseeing flight from Cradle Mountain, to Lake St. Clair and return. On board were the pilot and 4 passengers. The flight departed Cradle Mountain at approximately 1310 ESuT and tracked direct to Lake St Clair at 7000 ft due to turbulence. The aircraft then returned to Cradle Mountain. At approximately 1404, as the aircraft was approaching the airfield, the pilot configured the aircraft for a straight in approach to strip 02. The pilot had selected two stages of flap, and had reduced power to approximately 19 inches of manifold pressure. He reported that at approximately half a mile from the airfield the engine stopped without any prior warning. After completing trouble checks, the pilot became aware that the aircraft would not reach the airfield. He then manoeuvred the aircraft towards an open area on his right while broadcasting a MAYDAY call. Melbourne air traffic control acknowledged this call. The pilot then completed additional trouble checks and changed the fuel tank selection, but the engine failed to respond. The aircraft touched down heavily on the main wheels and slid approximately 40 metres before coming to a stop. During the touchdown and subsequent ground slide, the nose wheel detached from the aircraft, the propeller was damaged and the right wing was partially separated from the airframe. After the aircraft stopped the pilot checked the passengers and discovered that two of them had suffered serious injuries.
Probable cause:
The pilot reported that he had completed a daily inspection of the aircraft earlier in the morning. That inspection included assessing the fuel quantity on board the aircraft and completing a fuel drain and water check. Both of these checks did not reveal any problem with the fuel. The pilot estimated that there was approximately 185 litres of fuel on board the aircraft, 90 litres in the right tank and 95 litres in the left tank. The aircraft had last been refuelled the day previously from drum stock. The aircraft had completed two flights since that refuelling with no problems being reported. The engineers that recovered the aircraft reported that there was approximately 30 litres of fuel in the left tank and approximately 100 litres of fuel in the right tank. The C207 aircraft has a fuel selector in the cockpit that allows the pilot to supply fuel to the engine from either the right tank or the left tank, but not from both tanks simultaneously. The pilot reported that he conducted the flight with the fuel selector switched to the left tank. He also reported that he did not move the selector during the flight and only moved it to the right tank as part of his trouble checks when the engine failed. The pilot reported that he did not complete flight or fuel plans for the flight, but operated on previous knowledge from other flights. A post occurrence analysis of the weather indicated that the winds at 7000 feet were as forecast. Post flight analysis of the flight revealed that the aircraft would have required 57 litres of fuel to complete the flight, which included allowances for taxi and climb. The engine was sent by the owner to an engine overhaul facility for testing. The ATSB did not attend the testing of the engine. The engine was fitted to the test cell in the condition as removed from the aircraft. The engine was started and test run in accordance with the engine manufacturer's overhaul manual. The engine ran normally and all temperature and pressure limits were within normal ranges. The investigation was unable to determine why the engine failed to operate normally in the latter stages of the flight.
Final Report:

Crash of an Antonov AN-12BK in Kome

Date & Time: Nov 7, 2002 at 1130 LT
Type of aircraft:
Operator:
Registration:
4K-AZ21
Flight Type:
Survivors:
Yes
Schedule:
Bergen - Ostende - N'Djamena - Kome
MSN:
8 3 456 09
YOM:
1968
Flight number:
AZQ4132
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The four engine aircraft departed Bergen on a cargo flight to Kome with intermediate stops in Ostend and N'Djamena, carrying six crew members and a load of various goods. For unknown reasons, the aircraft landed 800 metres past the runway threshold (Kome's runway is 1,800 metres long). Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest in a field. All six occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of a Britten-Norman BN-2A-21 Islander in Tarakan: 7 killed

Date & Time: Nov 7, 2002 at 1027 LT
Type of aircraft:
Operator:
Registration:
PK-VIZ
Survivors:
Yes
Schedule:
Tarakan - Long Bawan
MSN:
697
YOM:
1973
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
7
Circumstances:
Shortly after takeoff from Tarakan Airport, en route to Long Bawan, the pilot encountered engine problems and decided to return. On approach, the aircraft stalled and crashed on the top of a hill located 1,500 metres short of runway. Three passengers were injured while seven other occupants were killed.
Probable cause:
Engine failure for unknown reasons.

Crash of a Fokker 50 in Luxembourg: 20 killed

Date & Time: Nov 6, 2002 at 1006 LT
Type of aircraft:
Operator:
Registration:
LX-LGB
Survivors:
Yes
Schedule:
Berlin – Luxembourg
MSN:
20221
YOM:
1991
Flight number:
LG9642
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
20
Captain / Total flying hours:
4242
Captain / Total hours on type:
2864.00
Copilot / Total flying hours:
1156
Copilot / Total hours on type:
443
Aircraft flight hours:
21836
Aircraft flight cycles:
24068
Circumstances:
The Fokker 27 Mk050 registered LX-LGB and operated by Luxair left Berlin on 6 November 2002 at 07h 40min on flight LG 9642/LH 2420 with destination Luxembourg. Cruising level was at FL180. At 08h 50min, Frankfurt Control asked the crew to stop descent at FL 90, direct to Diekirch and at 08h 52min the flight was transferred to Luxembourg Approach. They were instructed to enter the Diekirch hold at FL90, to expect later on vectors for an ILS 24 and were given the latest RVR readings. At 08h 59min, well before reaching the Diekirch hold, the aircraft was recleared to 3000ft QNH and to turn left heading one three zero. At this time the aircraft flew in the clear sky above a fog layer. RVR was two hundred seventy five meters. The crew evoked a go-around if the RVR was not three hundred meters whilst passing ELU (it’s minima for a category II approach). At 09h04 min 36s, the aircraft passed overhead ELU maintaining 3000ft QNH. At 09h04 min 57s, the ATC controller transmitted an RVR of three hundred meters. Power was further reduced, flaps 10 were selected and the landing gear was lowered. Immediately after the landing gear was lowered, the pitch angle of the two propellers simultaneously reached a value that is lower than the minimum values for flight. This propeller pitch setting involves a rapid decrease of speed and altitude. During the following seconds, the left engine stopped and then the right engine stopped. The flight data recorders, no longer powered ceased functioning. At 09h05 min 42s (radar time base), the aircraft disappeared from the radar screen. It was immediately found in a field seven hundred meters to the north of runway centreline 24 and three point five kilometres to the east of the threshold. Six people were critically injured while 16 others were killed. Within the following hours, four of the survivors died from their injuries. The only two survivors were a passenger, a French citizen, and the captain.
Probable cause:
The initial cause of the accident is the crew’s acceptance of the approach clearance although they were not prepared to it, namely the absence of preparation of a go-around. It led the crew to perform a series of improvised actions that ended in the prohibited override of the primary stop on the power levers and leading to an irreversible loss of control.
Contributory factors can be listed as follows:
1. A lack of preparation for the landing, initiated by unnecessary occupations resulting from an obtained RVR value, which was below their company approved minima, created a disorganisation in the cockpit, leading to uncoordinated actions by each crewmember.
2. Some procedures as laid down in the operations manual were not followed at some stage of the approach. All this did not directly cause the accident, but created an environment whereby individual actions were initiated to make a landing possible.
3. Routine and the will to arrive at destination may have put the crew in a psychological state of mind, which could have been the origin of the deviations from standard procedures as noticed.
4. The priority in the approach sequence given to the crew by ATC, which facilitated the traffic handling for the controller who was not aware of the operational consequences.
5. The low reliability of the installed secondary stop safety device that was favoured by the non-application of service bulletin ABSC SB Fo50-32-4. Also the mode of distribution of the safety information (Fokker Aircraft B.V. – Service letter 137) to the operator as well as the operator’s internal distribution to the crews, that did not guarantee that the crews were aware of the potential loss of secondary stop on propeller pitch control.
6. Latent shortcomings in the Authority and the organisational structure of the operator, in combination with poor application of SOPs by the crew.
Final Report:

Crash of a Fokker F27 Friendship 500RF in Sligo

Date & Time: Nov 2, 2002 at 1702 LT
Type of aircraft:
Operator:
Registration:
G-ECAT
Survivors:
Yes
Schedule:
Dublin - Sligo
MSN:
10672
YOM:
1984
Flight number:
ECY406
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5710
Captain / Total hours on type:
1176.00
Copilot / Total flying hours:
20117
Copilot / Total hours on type:
787
Aircraft flight hours:
27452
Circumstances:
The aircraft, a Fokker F27-500, registration G-ECAT, departed Dublin at 16.05 hrs (local time) for the 4th leg of a Public Service Obligation (PSO) rotation between Sligo in the North West of Ireland and Dublin. The aircraft had earlier departed Sligo for Dublin at 10.00 hrs, returned to Sligo at 12.30 hrs and departed once again for Dublin on time at 14.30 hrs. The Operator held the PSO contract to provide regular air service between Sligo and Dublin and also between Donegal (EIDL) and Dublin. The accident flight was delayed for 10 minutes as the flight to Donegal had been cancelled due to strong crosswinds at Donegal and arrangements had been made to fly these passengers to Sligo and bus them onwards to Donegal. The en-route segment of this flight was uneventful. At 16.22 hrs G-ECAT called Sligo on Tower frequency 122.10 Mhz and requested the latest weather conditions for Sligo. The Tower Controller transmitted the 16.30 hrs actual for Sligo, as presented at Section 1.7 Meteorological Information. At 16.50 hrs, the aircraft was handed over from Shannon Control to Sligo Tower, descending to 3,500 ft to the SLG beacon for NDB/DME approach to RWY 11. Sligo Tower then transmitted the Donegal weather, as presented at Section 1.7 Meteorological Information. At 16.53 hrs, the aircraft called overhead the SLG beacon and was cleared by Sligo Tower for the approach. At 17.00 hrs, G-ECAT reported at the Final Approach Fix (FAF) and was cleared to land by the Tower, giving a wind of 120 degrees 15 kt, gusting 29 kt. At 17.01 hrs, just prior to landing, G-ECAT was given a wind check of 120 degrees 15 kt, gusting 31 kt. At 17.02 hrs the aircraft made an initial touchdown at approximately the mid-point of the runway and appeared to a number of witnesses not to immediately decelerate. The aircraft continued down the runway until it departed the paved surface at the right hand side of the threshold of RWY 29. On seeing the aircraft pass the apron taxiway/runway intersection at an abnormally high speed, the Tower Controller immediately sounded the crash alarm. The aircraft continued on through a prepared run-off area at the end of the runway, for a further 50 metres, before coming to rest (17.02:30 hrs) with the main wheels embedded in boulders that formed part of an embankment leading down to the sea. The main wheels were approximately one metre short of where the boulders fall away into the sea. The nose wheel, cockpit and forward section of the fuselage cleared the top of the boulder embankment and the aircraft tilted approximately 15-20 degrees nose down onto the outgoing tide. Full tide was due at 04.00 hrs the following day at a depth of 3.9 meters. The Tower Controller immediately contacted the Shannon ATC Station Manager advising of the runway excursion and called 999 to request Gardaí, Fire Brigade and Ambulance assistance.
Probable cause:
The probable cause of this accident was a fast, low approach, leading to the aircraft landing late, beyond the normal touch down point, thereby making it impossible to stop the aircraft on the remaining runway available.
Contributory cause:
1. The lack of an adequate overrun area before an aircraft, failing to stop on the runway, enters the sea.
2. The lack of experience of the Operator in scheduled air operations.
3. The changing operational management structure and uncertain nature of the direction of the company with regard to aircraft type and network development.
Final Report:

Crash of a Douglas DC-9-32 in Monterrey

Date & Time: Oct 31, 2002 at 2215 LT
Type of aircraft:
Operator:
Registration:
XA-AMF
Survivors:
Yes
Schedule:
Guadalajara – Monterrey
MSN:
48130
YOM:
1980
Flight number:
AM254
Country:
Crew on board:
4
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach and landing at Monterrey-General Mariano Escobido Airport were completed by night and poor weather conditions with limited visibility due to heavy rain falls and mist. At the time of the accident, runway 29 threshold was displaced by 900 metres, reducing the landing distance available from 3,000 metres to 2,100 metres due to construction works. Following a wrong approach configuration, the aircraft landed too far down a wet runway and was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest 60 metres further with the right partially torn off. 11 passengers were injured while 79 other occupants were unhurt.

Crash of a Beechcraft A100 King Air in Eveleth: 8 killed

Date & Time: Oct 25, 2002 at 1022 LT
Type of aircraft:
Operator:
Registration:
N41BE
Survivors:
No
Schedule:
Saint-Paul – Eveleth
MSN:
B-245
YOM:
1979
Flight number:
N41BE
Crew on board:
2
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
5116
Captain / Total hours on type:
200.00
Copilot / Total flying hours:
701
Copilot / Total hours on type:
107
Aircraft flight hours:
12726
Circumstances:
On October 25, 2002, about 1022 central daylight time, a Raytheon (Beechcraft) King Air A100, N41BE, operated by Aviation Charter, Inc., crashed while the flight crew was attempting to execute the VOR approach to runway 27 at Eveleth-Virginia Municipal Airport, Eveleth, Minnesota. The crash site was located about 1.8 nautical miles southeast of the approach end of runway 27. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces and a post crash fire. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand passenger charter flight. Instrument meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. Among those on board were Paul Wellstone, Senator of Minnesota, his wife Sheila and one of his three children Marcia.
Probable cause:
The flight crew's failure to maintain adequate airspeed, which led to an aerodynamic stall from which they did not recover.
Final Report: